Healthcare Provider Details

I. General information

NPI: 1992192561
Provider Name (Legal Business Name): SAMANTHA JAMISON PEASE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1251 NILLES RD STE 5
FAIRFIELD OH
45014
US

IV. Provider business mailing address

1251 NILLES RD STE 5
FAIRFIELD OH
45014-7205
US

V. Phone/Fax

Practice location:
  • Phone: 513-939-0300
  • Fax: 513-939-0310
Mailing address:
  • Phone: 513-939-0300
  • Fax: 513-939-0310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.1600574
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberS.1400042-TRNE
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1901614
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: