MEDICARE: BONNIE EIDENS LISW, CEAP, LLC

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1619105699
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BONNIE EIDENS LISW, CEAP, LLC

Provider Business Mailing Address
First Line	:	850 S BROADWAY
Second Line	:
City	:	GENEVA
State	:	OH
Zip	:	44041-9146
Country	:	US
Telephone Number	:	440-813-5071
Fax Number	:	440-466-0969

Provider Business Practice Location Address
First Line	:	850 S BROADWAY
Second Line	:
City	:	GENEVA
State	:	OH
Zip	:	44041-9146
Country	:	US
Telephone Number	:	440-813-5071
Fax Number	:	440-466-0969

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. BONNIE LOUISE EIDENS
Credential	:	LISW, CEAP
Telephone Number	:	440-813-5071

Provider Enumeration Date	:	06/29/2009
Last Update Date	:	06/29/2009

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