Provider Demographics
NPI:1144921677
Name:LISY, JOHN J JR (LISW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:LISY
Suffix:JR
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2419 DERBYSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44106-2725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24500 CENTER RIDGE RD STE 110
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5604
Practice Address - Country:US
Practice Address - Phone:440-787-6311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0000387101YM0800X
OHI00009931041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health