Healthcare Provider Details

I. General information

NPI: 1306186648
Provider Name (Legal Business Name): MARY ANNE MAYLE LISWS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2013
Last Update Date: 06/03/2020
Certification Date: 06/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MANOR DR
PERRYSBURG OH
43551-3118
US

IV. Provider business mailing address

1100 SHAWNEE RD
LIMA OH
45805-3583
US

V. Phone/Fax

Practice location:
  • Phone: 419-874-0306
  • Fax: 419-874-9295
Mailing address:
  • Phone: 419-999-2010
  • Fax: 419-999-6284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1201489-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: