Healthcare Provider Details

I. General information

NPI: 1871865303
Provider Name (Legal Business Name): WALTER B BOHL LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2012
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 S HIGH ST
COLUMBUS OH
43215-5602
US

IV. Provider business mailing address

1801 WATERMARK DR STE 200
COLUMBUS OH
43215-7088
US

V. Phone/Fax

Practice location:
  • Phone: 866-438-6508
  • Fax: 614-227-9445
Mailing address:
  • Phone: 888-202-2965
  • Fax: 614-487-8769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0005241
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: