Healthcare Provider Details

I. General information

NPI: 1417358250
Provider Name (Legal Business Name): AMBER STANLEY LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2014
Last Update Date: 09/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4104 GERMANTOWN PIKE
DAYTON OH
45417-6118
US

IV. Provider business mailing address

534 SAGE RUN DR
LEBANON OH
45036-3918
US

V. Phone/Fax

Practice location:
  • Phone: 937-263-0060
  • Fax:
Mailing address:
  • Phone: 937-263-0060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1100216
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: