Provider Demographics
NPI:1255612628
Name:WIBLE, ALISSA S (LISW-S)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:S
Last Name:WIBLE
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2181 BRIARWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2833
Mailing Address - Country:US
Mailing Address - Phone:440-574-1794
Mailing Address - Fax:
Practice Address - Street 1:20525 CENTER RIDGE RD
Practice Address - Street 2:SUITE 303
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-3437
Practice Address - Country:US
Practice Address - Phone:440-574-1794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI1440201-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268768Medicaid