Healthcare Provider Details

I. General information

NPI: 1528431657
Provider Name (Legal Business Name): YASHAUNA WALLACE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2015
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6809 MAIN ST UNIT 953
CINCINNATI OH
45244-3470
US

IV. Provider business mailing address

6809 MAIN ST UNIT 953
CINCINNATI OH
45244-3470
US

V. Phone/Fax

Practice location:
  • Phone: 513-813-1908
  • Fax:
Mailing address:
  • Phone: 513-813-1908
  • Fax: 513-725-1995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1801335
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC014421
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License NumberDOU.000007
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: