Healthcare Provider Details

I. General information

NPI: 1104631977
Provider Name (Legal Business Name): GRACE E HENRY LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 ALBERT SABIN WAY
CINCINNATI OH
45229-2838
US

IV. Provider business mailing address

6769 N WICKHAM RD STE B101
MELBOURNE FL
32940-2048
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-9067
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2506879
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: