Healthcare Provider Details

I. General information

NPI: 1114984614
Provider Name (Legal Business Name): DIANE MARIE GABLE LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

658 W MARKET ST SUITE 101
LIMA OH
45801-4653
US

IV. Provider business mailing address

658 W MARKET ST SUITE 101
LIMA OH
45801-4653
US

V. Phone/Fax

Practice location:
  • Phone: 419-222-1527
  • Fax: 419-222-3586
Mailing address:
  • Phone: 419-222-1527
  • Fax: 419-222-3586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-0009529
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierI-0009529
Identifier TypeOTHER
Identifier StateOH
Identifier IssuerLISW
# 2
Identifier000000388099
Identifier TypeOTHER
Identifier StateOH
Identifier IssuerANTHEM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: