MEDICARE: MICHELE KELLY 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 0900082	OH

General Provider Information

NPI Number	:	1811328735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELE KELLY LISW

Provider Business Mailing Address
First Line	:	791 HAVENWOOD DR
Second Line	:
City	:	NEW FRANKLIN
State	:	OH
Zip	:	44319-4238
Country	:	US
Telephone Number	:	330-475-5095
Fax Number	:

Provider Business Practice Location Address
First Line	:	791 HAVENWOOD DR
Second Line	:
City	:	NEW FRANKLIN
State	:	OH
Zip	:	44319-4238
Country	:	US
Telephone Number	:	330-475-5095
Fax Number	:

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

Provider Enumeration Date	:	12/02/2013
Last Update Date	:	12/02/2013

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