Healthcare Provider Details

I. General information

NPI: 1881867182
Provider Name (Legal Business Name): GREG DOUGLAS LISW-S, CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 07/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7341 S TIMBERLANE DR
CINCINNATI OH
45243-1843
US

IV. Provider business mailing address

7341 S TIMBERLANE DR
CINCINNATI OH
45243-1843
US

V. Phone/Fax

Practice location:
  • Phone: 513-793-3355
  • Fax:
Mailing address:
  • Phone: 513-793-3355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCOA.17489-NP
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0700380-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: