Healthcare Provider Details

I. General information

NPI: 1386176493
Provider Name (Legal Business Name): MATTHEW KSIAZK LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 03/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 GRANDVIEW AVE
COLUMBUS OH
43215-1123
US

IV. Provider business mailing address

3991 KUL CIR S
HILLIARD OH
43026-3854
US

V. Phone/Fax

Practice location:
  • Phone: 614-258-9927
  • Fax:
Mailing address:
  • Phone: 440-315-0723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1700091
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: