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NPI Code Detail

MEDICARE: GINA LICURSI LSW

MEDICARE: GINA LICURSI LSW
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
11041C0700XClinical Social Worker1600350OH

General Provider Information

NPI Number : 1891226411
Entity Type Code : Individual
Provider Name (Legal Business Name) : GINA LICURSI LSW
Provider Business Mailing Address
First Line : 10025 CHILLICOTHE RD
Second Line :
City : KIRTLAND
State : OH
Zip : 44094-9734
Country : US
Telephone Number : 440-622-2404
Fax Number :
Provider Business Practice Location Address
First Line : 12041 RAVENNA RD
Second Line :
City : CHARDON
State : OH
Zip : 44024-7008
Country : US
Telephone Number : 440-286-7154
Fax Number : 440-286-1037
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/24/2017
Last Update Date : 03/24/2017

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