MEDICARE: MRS. ANGEL MICHELLE BERNARD 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.2506967	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609556935
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANGEL MICHELLE BERNARD LISW

Provider Business Mailing Address
First Line	:	139 WAVERLY AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45405-2231
Country	:	US
Telephone Number	:	937-986-9629
Fax Number	:

Provider Business Practice Location Address
First Line	:	78 E FRANKLIN ST
Second Line	:
City	:	CENTERVILLE
State	:	OH
Zip	:	45459-5914
Country	:	US
Telephone Number	:	866-534-2639
Fax Number	:	800-480-7578

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

Provider Enumeration Date	:	07/21/2023
Last Update Date	:	09/09/2025

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