Healthcare Provider Details

I. General information

NPI: 1538292651
Provider Name (Legal Business Name): ROBERT L MARION LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2434 RICHMILLER LN UNIT F
BELPRE OH
45714-1075
US

IV. Provider business mailing address

PO BOX 188
CHILLICOTHEE OH
45601-0188
US

V. Phone/Fax

Practice location:
  • Phone: 740-423-8095
  • Fax: 740-423-8096
Mailing address:
  • Phone: 740-773-4366
  • Fax: 740-775-7855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI0700018
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: