Healthcare Provider Details

I. General information

NPI: 1003432303
Provider Name (Legal Business Name): LISA MARIE SANDERS CDCA 165881
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7350 MONTGOMERY RD STE 516
CINCINNATI OH
45236-7500
US

IV. Provider business mailing address

PO BOX 36516
CINCINNATI OH
45236-0516
US

V. Phone/Fax

Practice location:
  • Phone: 513-239-7361
  • Fax:
Mailing address:
  • Phone: 513-239-7361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number165881
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: