Healthcare Provider Details

I. General information

NPI: 1063803310
Provider Name (Legal Business Name): JOHN HURLEY LISW-SUPV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 CAMPBELL DR
IRONTON OH
45638-2301
US

IV. Provider business mailing address

305 N 5TH ST
IRONTON OH
45638-1578
US

V. Phone/Fax

Practice location:
  • Phone: 740-534-9202
  • Fax: 740-532-4777
Mailing address:
  • Phone: 740-532-3534
  • Fax: 740-532-4859

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0001632-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: