Healthcare Provider Details

I. General information

NPI: 1396048161
Provider Name (Legal Business Name): ANDREW MADISON WINTERS LISWS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 12/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 DELTA AVE STE A
CINCINNATI OH
45208-3164
US

IV. Provider business mailing address

330 PARK AVE
NEWPORT KY
41071-4577
US

V. Phone/Fax

Practice location:
  • Phone: 513-675-3833
  • Fax: 513-651-2310
Mailing address:
  • Phone: 513-675-3833
  • Fax: 513-651-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0009843-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: