Basic Information
| Provider Information | |||||||||
| NPI: | 1023141470 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DITZEL | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | KAY | ||||||||
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| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14751 FERNWAY AVE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441111108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164769987 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8445 MUNSON RD | ||||||||
| Address2: | |||||||||
| City: | MENTOR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440602410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402551700 | ||||||||
| FaxNumber: | 4402052417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S30544 | OH | X | Behavioral Health & Social Service Providers | Social Worker | 1041S0200X | S30544 | OH | X | Behavioral Health & Social Service Providers | Social Worker | School |
No ID Information.