MEDICARE: ELIZABETH GRACE CHUPA LISW

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	I.700212	OH

General Provider Information

NPI Number	:	1265944169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH GRACE CHUPA LISW

Provider Business Mailing Address
First Line	:	4785 MEMPHIS AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44144-1916
Country	:	US
Telephone Number	:	216-563-1180
Fax Number	:	440-815-2245

Provider Business Practice Location Address
First Line	:	4785 MEMPHIS AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44144-1916
Country	:	US
Telephone Number	:	937-243-6560
Fax Number	:

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

Provider Enumeration Date	:	11/01/2017
Last Update Date	:	09/29/2021

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