Healthcare Provider Details

I. General information

NPI: 1982053047
Provider Name (Legal Business Name): CHRISTINA PETTY LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2016
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 JACKSON ST STE C
GREENVILLE OH
45331-1396
US

IV. Provider business mailing address

5735 MEEKER RD
GREENVILLE OH
45331-1186
US

V. Phone/Fax

Practice location:
  • Phone: 937-547-2319
  • Fax:
Mailing address:
  • Phone: 937-548-3806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.1303319
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2405473
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: