1457046161 NPI number — MARY K LAWRENCE LISW

Table of content: MARY K LAWRENCE LISW (NPI 1457046161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457046161 NPI number — MARY K LAWRENCE LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAWRENCE
Provider First Name:
MARY
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW
Provider Gender Code:
X

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457046161
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7665 MENTOR AVE # 311
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENTOR
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44060-5409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2061 CORNELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44106-3808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
162-844-7224
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/07/2023

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  I.2304596 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)