MEDICARE: MR. MARK W FRESHLEY 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	104100000X	Social Worker	I-5327	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000002145	OTHER	OH	ANTHEM PIN

General Provider Information

NPI Number	:	1336368851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK W FRESHLEY LISW

Provider Business Mailing Address
First Line	:	8040 HOSBROOK RD STE 320
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45236-2908
Country	:	US
Telephone Number	:	513-861-9797
Fax Number	:	513-861-3510

Provider Business Practice Location Address
First Line	:	8040 HOSBROOK RD STE 320
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45236-2908
Country	:	US
Telephone Number	:	513-861-9797
Fax Number	:	513-861-3510

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

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	03/17/2018

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