MEDICARE: MR. CHARLES JOSEPH III LISW-S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I0005671	OH

General Provider Information

NPI Number	:	1184164378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES JOSEPH III LISW-S

Provider Business Mailing Address
First Line	:	4509 FRANKLIN BLVD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44102-3427
Country	:	US
Telephone Number	:	216-390-9558
Fax Number	:

Provider Business Practice Location Address
First Line	:	4509 FRANKLIN BLVD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44102-3427
Country	:	US
Telephone Number	:	216-390-9558
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/07/2017
Last Update Date	:	03/07/2017

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