Healthcare Provider Details

I. General information

NPI: 1770622144
Provider Name (Legal Business Name): MARYBETH LITTLE LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 MARION PIKE STE 1
COAL GROVE OH
45638-2958
US

IV. Provider business mailing address

323 MARION PIKE STE 1
COAL GROVE OH
45638-2958
US

V. Phone/Fax

Practice location:
  • Phone: 740-237-4981
  • Fax:
Mailing address:
  • Phone: 740-237-4981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberKY-3038
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.1450659-SUPV
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberI.1450659-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: