Healthcare Provider Details

I. General information

NPI: 1285985564
Provider Name (Legal Business Name): MARTHA A LISCANO, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2012
Last Update Date: 09/26/2012
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:
Mailing address:
  • Phone: 614-451-9401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI0000992
License Number StateOH

VIII. Authorized Official

Name: LAURA C MARADO
Title or Position: PRACTICE MANAGER
Credential:
Phone: 614-326-0511