Healthcare Provider Details

I. General information

NPI: 1356765671
Provider Name (Legal Business Name): MARK A WARD LISW-S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 OLD HARSHMAN RD
RIVERSIDE OH
45431-1238
US

IV. Provider business mailing address

805 OLD HARSHMAN RD
RIVERSIDE OH
45431-1238
US

V. Phone/Fax

Practice location:
  • Phone: 937-259-6630
  • Fax: 937-259-6628
Mailing address:
  • Phone: 937-259-6630
  • Fax: 937-259-6628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number1041S0200X
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: