Healthcare Provider Details

I. General information

NPI: 1164456232
Provider Name (Legal Business Name): MARTHA A LISCANO MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 01/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

941 CHATHAM LN #103
COLUMBUS OH
43221-2416
US

IV. Provider business mailing address

941 CHATHAM LN #103
COLUMBUS OH
43221-2416
US

V. Phone/Fax

Practice location:
  • Phone: 614-451-9401
  • Fax: 614-451-8113
Mailing address:
  • Phone: 614-451-9401
  • Fax: 614-451-8113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI0000992
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: