Healthcare Provider Details

I. General information

NPI: 1992203053
Provider Name (Legal Business Name): EMILY MALONE LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 10/27/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 SR 664 N
LOGAN OH
43138
US

IV. Provider business mailing address

PO BOX 188
CHILLICOTHEE OH
45601-0188
US

V. Phone/Fax

Practice location:
  • Phone: 740-385-6594
  • Fax: 740-774-6617
Mailing address:
  • Phone: 740-773-4366
  • Fax: 740-775-7855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: