Healthcare Provider Details

I. General information

NPI: 1609421296
Provider Name (Legal Business Name): ASHLEY BUSH LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ASHLEY ALBERTSON LISW

II. Dates (important events)

Enumeration Date: 08/09/2019
Last Update Date: 09/29/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 E DUDLEY ST
MAUMEE OH
43537-3366
US

IV. Provider business mailing address

112 E DUDLEY ST
MAUMEE OH
43537-3366
US

V. Phone/Fax

Practice location:
  • Phone: 419-575-3490
  • Fax: 419-715-0776
Mailing address:
  • Phone: 419-575-3490
  • Fax: 419-715-0776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1500813-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: