MEDICARE: AIRIELLE BANASZAK LISW-S

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.1000019.SUPV	OH

General Provider Information

NPI Number	:	1780128959
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AIRIELLE BANASZAK LISW-S

Provider Business Mailing Address
First Line	:	21245 LORAIN RD STE 201
Second Line	:
City	:	FAIRVIEW PARK
State	:	OH
Zip	:	44126-2140
Country	:	US
Telephone Number	:	216-337-3189
Fax Number	:

Provider Business Practice Location Address
First Line	:	21245 LORAIN RD STE 201
Second Line	:
City	:	FAIRVIEW PARK
State	:	OH
Zip	:	44126-2140
Country	:	US
Telephone Number	:	216-337-3189
Fax Number	:

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

Provider Enumeration Date	:	12/07/2016
Last Update Date	:	03/07/2024

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