Healthcare Provider Details

I. General information

NPI: 1003967480
Provider Name (Legal Business Name): MARY BETH NIKLAS LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4240 HUNT RD
CINCINNATI OH
45242-6612
US

IV. Provider business mailing address

4240 HUNT RD
CINCINNATI OH
45242-6612
US

V. Phone/Fax

Practice location:
  • Phone: 513-891-0650
  • Fax: 513-891-2838
Mailing address:
  • Phone: 513-891-0650
  • Fax: 513-891-2838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI0005305
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1528
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: