Healthcare Provider Details

I. General information

NPI: 1790776649
Provider Name (Legal Business Name): SUZANNE E KINCAID LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1299 OLENTANGY RIVER RD
COLUMBUS OH
43212-3135
US

IV. Provider business mailing address

1299 OLENTANGY RIVER RD SUITE 103
COLUMBUS OH
43212-3135
US

V. Phone/Fax

Practice location:
  • Phone: 614-566-4710
  • Fax: 614-566-6846
Mailing address:
  • Phone: 614-566-4278
  • Fax: 614-566-5424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI0005111
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: