Healthcare Provider Details

I. General information

NPI: 1972565349
Provider Name (Legal Business Name): ELENA ABIAD SUTHERLAND LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 DELAWARE AVE
MARION OH
43301-1814
US

IV. Provider business mailing address

L-3549
COLUMBUS OH
43260-0001
US

V. Phone/Fax

Practice location:
  • Phone: 740-383-7910
  • Fax: 740-375-8129
Mailing address:
  • Phone: 740-383-7927
  • Fax: 740-383-7942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI0002165
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: