Healthcare Provider Details

I. General information

NPI: 1437130994
Provider Name (Legal Business Name): JOHN DAVID BALDWIN LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 11/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21ST ST. BLDG 2437
FT. CAMPBELL KY
42223
US

IV. Provider business mailing address

21ST ST. BLDG 2437
FT. CAMPBELL KY
42223
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8967
  • Fax: 270-956-0219
Mailing address:
  • Phone: 270-798-8967
  • Fax: 270-956-0219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM06007
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: