MEDICARE: LA' TONYA FISHER-GRACE 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	101Y00000X	Counselor
2	101YM0800X	Mental Health Counselor
3	172V00000X	Community Health Worker
4	251C00000X	Developmentally Disabled Services Day Training Agency
5	261QA0600X	Adult Day Care Clinic/Center
6	347C00000X	Private Vehicle
7	3747P1801X	Personal Care Attendant
8	374U00000X	Home Health Aide
9	376J00000X	Homemaker
10	1041C0700X	Clinical Social Worker	I.1901414	OH

General Provider Information

NPI Number	:	1548809387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LA' TONYA FISHER-GRACE LISW

Provider Business Mailing Address
First Line	:	6238 RANDOLPH RD
Second Line	:
City	:	BEDFORD HEIGHTS
State	:	OH
Zip	:	44146-3912
Country	:	US
Telephone Number	:	216-392-2992
Fax Number	:

Provider Business Practice Location Address
First Line	:	6238 RANDOLPH RD
Second Line	:
City	:	BEDFORD HEIGHTS
State	:	OH
Zip	:	44146-3912
Country	:	US
Telephone Number	:	216-392-2992
Fax Number	:

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

Provider Enumeration Date	:	12/26/2019
Last Update Date	:	12/26/2019

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