Healthcare Provider Details

I. General information

NPI: 1609094853
Provider Name (Legal Business Name): MARAE MARTIN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 E MAIN ST
AMELIA OH
45102-1992
US

IV. Provider business mailing address

37 E MAIN ST
AMELIA OH
45102-1992
US

V. Phone/Fax

Practice location:
  • Phone: 513-753-9964
  • Fax: 513-753-9968
Mailing address:
  • Phone: 513-753-9964
  • Fax: 513-753-9968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0009351
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: