Healthcare Provider Details

I. General information

NPI: 1912862228
Provider Name (Legal Business Name): LISA HEAVENER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

794 MCPHERSON AVE
CINCINNATI OH
45205-2138
US

IV. Provider business mailing address

794 MCPHERSON AVE
CINCINNATI OH
45205-2138
US

V. Phone/Fax

Practice location:
  • Phone: 513-383-1530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.007177
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: