Healthcare Provider Details

I. General information

NPI: 1619547494
Provider Name (Legal Business Name): LISA KOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2021
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1390 BRYSON RD
COLUMBUS OH
43224-2013
US

IV. Provider business mailing address

1390 BRYSON RD
COLUMBUS OH
43224-2013
US

V. Phone/Fax

Practice location:
  • Phone: 954-471-6075
  • Fax:
Mailing address:
  • Phone: 954-471-6075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH19399
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2303942
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: