Healthcare Provider Details

I. General information

NPI: 1144490087
Provider Name (Legal Business Name): MEREDITH JO LAYMAN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEREDITH JO BRODIE

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 FORT AMANDA RD
LIMA OH
45804-3728
US

IV. Provider business mailing address

1100 SHAWNEE RD
LIMA OH
45805-3529
US

V. Phone/Fax

Practice location:
  • Phone: 419-999-2055
  • Fax: 419-999-2058
Mailing address:
  • Phone: 419-999-2010
  • Fax: 419-999-6284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW022255
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI0800064
License Number StateOH

VII. Legacy identifiers

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

# 1
Identifier0362841
Identifier TypeMEDICAID
Identifier StateOH
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: