Healthcare Provider Details

I. General information

NPI: 1699522466
Provider Name (Legal Business Name): SEAN YOUNG LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 S 18TH ST
COLUMBUS OH
43205-2654
US

IV. Provider business mailing address

700 CHILDRENS DR
COLUMBUS OH
43205-2639
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-4545
  • Fax: 614-722-4575
Mailing address:
  • Phone: 614-722-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2304284
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: