Healthcare Provider Details

I. General information

NPI: 1619702537
Provider Name (Legal Business Name): LISA DOUGLAS LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

700 BRYDEN ROAD SUITE 122
COLUMBUS OH
43215
US

IV. Provider business mailing address

3927 ABBIE COVE LN.
CANAL WINCHESTER OH
43110
US

V. Phone/Fax

Practice location:
  • Phone: 614-681-0012
  • Fax:
Mailing address:
  • Phone: 614-282-1202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1600288-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: