MEDICARE: DANIEL LEE 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.1200936	OH

General Provider Information

NPI Number	:	1497009740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL LEE LISW

Provider Business Mailing Address
First Line	:	3595 SULLIVANT AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-2121
Country	:	US
Telephone Number	:	614-752-0333
Fax Number	:	614-995-3268

Provider Business Practice Location Address
First Line	:	3595 SULLIVANT AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-2121
Country	:	US
Telephone Number	:	614-752-0333
Fax Number	:	614-995-3268

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

Provider Enumeration Date	:	11/07/2012
Last Update Date	:	11/07/2012

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