Provider Demographics
NPI:1912628074
Name:LISWITH, THEODORE JOHN (LCSW)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:JOHN
Last Name:LISWITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 BRUCE B. DOWNS BLVD
Mailing Address - Street 2:SOCIAL WORK SERVICE MAIL CODE 122
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612
Mailing Address - Country:US
Mailing Address - Phone:813-394-1473
Mailing Address - Fax:
Practice Address - Street 1:1300 BRUCE B. DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612
Practice Address - Country:US
Practice Address - Phone:813-394-1473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW119661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical