Healthcare Provider Details

I. General information

NPI: 1326294364
Provider Name (Legal Business Name): CHASITY NICOLE CARRERA MSW, LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHASITY TIETJE

II. Dates (important events)

Enumeration Date: 08/11/2008
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E MAIN ST
LEIPSIC OH
45856-9326
US

IV. Provider business mailing address

1100 SHAWNEE RD
LIMA OH
45805-3529
US

V. Phone/Fax

Practice location:
  • Phone: 419-999-2010
  • Fax: 419-999-6284
Mailing address:
  • Phone: 419-999-2010
  • Fax: 419-999-6284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberI.1000325-SUPV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS0031200
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.1000325-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: