Healthcare Provider Details

I. General information

NPI: 1174006027
Provider Name (Legal Business Name): MARIAN HEYINK LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 GRANGER RD
MEDINA OH
44256-8478
US

IV. Provider business mailing address

3952 SHELLY DR
SEVEN HILLS OH
44131-6266
US

V. Phone/Fax

Practice location:
  • Phone: 330-618-6010
  • Fax:
Mailing address:
  • Phone: 216-314-8985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0003958
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: