Healthcare Provider Details

I. General information

NPI: 1811242803
Provider Name (Legal Business Name): GRIFFIN LONG LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15550 DURSTINE RD
DUNDEE OH
44624-9428
US

IV. Provider business mailing address

PO BOX 265
MOUNT EATON OH
44659-0265
US

V. Phone/Fax

Practice location:
  • Phone: 330-359-6100
  • Fax:
Mailing address:
  • Phone: 330-359-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1600257
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: