Healthcare Provider Details

I. General information

NPI: 1982365995
Provider Name (Legal Business Name): MIKAYLA BLISS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 09/06/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 S FRONT ST
FREMONT OH
43420-3021
US

IV. Provider business mailing address

200 N PENNSYLVANIA AVE
FREMONT OH
43420-4342
US

V. Phone/Fax

Practice location:
  • Phone: 567-280-4023
  • Fax:
Mailing address:
  • Phone: 419-577-8203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.162470
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2106809
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: