MEDICARE: STEPHAYNE JOHANNE HARRIS 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	104100000X	Social Worker	I5333	OH

General Provider Information

NPI Number	:	1720062565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHAYNE JOHANNE HARRIS LISW

Provider Business Mailing Address
First Line	:	3796 BROADWAY
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-2235
Country	:	US
Telephone Number	:	614-871-0035
Fax Number	:	614-539-0069

Provider Business Practice Location Address
First Line	:	3796 BROADWAY
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-2235
Country	:	US
Telephone Number	:	614-871-0035
Fax Number	:	614-539-0069

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

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	07/08/2007

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