Healthcare Provider Details

I. General information

NPI: 1174805105
Provider Name (Legal Business Name): NANCY LOUISE GOSZTYLA LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 S SOUDER AVE
COLUMBUS OH
43222-1535
US

IV. Provider business mailing address

1485 BORROR RD
GROVE CITY OH
43123-8972
US

V. Phone/Fax

Practice location:
  • Phone: 574-546-1900
  • Fax:
Mailing address:
  • Phone: 614-801-9568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI- 005579
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-5579
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: