Healthcare Provider Details

I. General information

NPI: 1891884383
Provider Name (Legal Business Name): JUDY IRENE MOORE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IRENE MOORE LISW

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY FAMILY PHYSICIANS INC 141 HEALTH PROF BLDG
CINCINNATI OH
45267-0001
US

IV. Provider business mailing address

2830 VICTORY PKWY STE 120
CINCINNATI OH
45206-1786
US

V. Phone/Fax

Practice location:
  • Phone: 513-558-4021
  • Fax: 513-558-3030
Mailing address:
  • Phone: 513-245-3052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0003865
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: