Healthcare Provider Details

I. General information

NPI: 1114192549
Provider Name (Legal Business Name): KARI LINAE DOUGLAS LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2008
Last Update Date: 04/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

788 LEXINGTON AVE
MANSFIELD OH
44907-1921
US

IV. Provider business mailing address

14 E GAYLORD AVE
SHELBY OH
44875-1604
US

V. Phone/Fax

Practice location:
  • Phone: 419-756-2828
  • Fax:
Mailing address:
  • Phone: 419-342-2265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI0029630
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: