Healthcare Provider Details

I. General information

NPI: 1225137219
Provider Name (Legal Business Name): KATHLEEN MARIE SHANNON LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 09/03/2020
Certification Date: 09/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 TRAILWOOD DR
BOARDMAN OH
44512-5007
US

IV. Provider business mailing address

615 ELSINORE PL STE 200
CINCINNATI OH
45202-1459
US

V. Phone/Fax

Practice location:
  • Phone: 513-834-7063
  • Fax: 513-873-1567
Mailing address:
  • Phone: 513-834-7063
  • Fax: 513-873-1567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.0003968-SUPV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI0003968
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: