Healthcare Provider Details

I. General information

NPI: 1518189364
Provider Name (Legal Business Name): DOUGLAS CONLEY LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 GILBERT AVE
CINCINNATI OH
45206-1210
US

IV. Provider business mailing address

2415 AUBURN AVE
CINCINNATI OH
45219-2701
US

V. Phone/Fax

Practice location:
  • Phone: 513-281-4116
  • Fax: 513-281-1492
Mailing address:
  • Phone: 513-221-4949
  • Fax: 513-241-4191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0001527
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: