Healthcare Provider Details

I. General information

NPI: 1548809619
Provider Name (Legal Business Name): STACEY HUNTWORK LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2652 KULL RD
LANCASTER OH
43130-7707
US

IV. Provider business mailing address

2652 KULL RD
LANCASTER OH
43130-7707
US

V. Phone/Fax

Practice location:
  • Phone: 740-687-0835
  • Fax:
Mailing address:
  • Phone: 740-687-0835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.1901419
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: