MEDICARE: WILLIAM RANDLE 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	I10245	OH

General Provider Information

NPI Number	:	1821181637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM RANDLE LISW

Provider Business Mailing Address
First Line	:	445 E DUBLIN GRANVILLE RD
Second Line	:	BLDG N
City	:	WORTHINGTON
State	:	OH
Zip	:	43085-3192
Country	:	US
Telephone Number	:	614-293-9550
Fax Number	:	614-293-9549

Provider Business Practice Location Address
First Line	:	500 E OLIVE AVE STE 240
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91501-2171
Country	:	US
Telephone Number	:	614-293-9550
Fax Number	:	614-293-9549

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	09/09/2020

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