Healthcare Provider Details

I. General information

NPI: 1982278925
Provider Name (Legal Business Name): KATHERINE HERZOG LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2021
Last Update Date: 05/14/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 S JEFFERSON AVE
PLAIN CITY OH
43064-4137
US

IV. Provider business mailing address

500 LONDON AVE
MARYSVILLE OH
43040-5512
US

V. Phone/Fax

Practice location:
  • Phone: 614-873-3434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2002022
License Number StateOH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: