MEDICARE: SARAH DEKELAITA 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.1700054	OH

General Provider Information

NPI Number	:	1710413471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH DEKELAITA LISW

Provider Business Mailing Address
First Line	:	415 GLENSPRINGS DR
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45246-2317
Country	:	US
Telephone Number	:	513-771-9600
Fax Number	:	513-771-2546

Provider Business Practice Location Address
First Line	:	415 GLENSPRINGS DR
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45246-2317
Country	:	US
Telephone Number	:	513-771-9600
Fax Number	:	513-771-2546

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

Provider Enumeration Date	:	05/02/2017
Last Update Date	:	05/02/2017

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