Healthcare Provider Details

I. General information

NPI: 1205463437
Provider Name (Legal Business Name): ELIZABETH DELIA STAAB LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 ALBERT SABIN WAY
CINCINNATI OH
45229-2838
US

IV. Provider business mailing address

311 ALBERT SABIN WAY
CINCINNATI OH
45229-2838
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-9006
  • Fax:
Mailing address:
  • Phone: 513-558-9006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.1904413
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2405590
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: