MEDICARE: MR. PETET O PRINZ LISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	8667	OH

General Provider Information

NPI Number	:	1215067673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PETET O PRINZ LISW

Provider Business Mailing Address
First Line	:	5936 GLENWAY AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45238-2009
Country	:	US
Telephone Number	:	513-922-1660
Fax Number	:	513-922-6230

Provider Business Practice Location Address
First Line	:	3557 SPRINGDALE RD
Second Line	:	BLDG. C
City	:	CINCINNATI
State	:	OH
Zip	:	45251-1314
Country	:	US
Telephone Number	:	513-922-1660
Fax Number	:	513-922-6230

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/08/2007

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