Healthcare Provider Details

I. General information

NPI: 1073027686
Provider Name (Legal Business Name): ALEXIS WITTE LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 PARK AVE W
MANSFIELD OH
44906
US

IV. Provider business mailing address

342 HANFORD ST
COLUMBUS OH
43206-3659
US

V. Phone/Fax

Practice location:
  • Phone: 419-528-5993
  • Fax:
Mailing address:
  • Phone: 513-300-0866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI.1700194
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: