Healthcare Provider Details

I. General information

NPI: 1114912805
Provider Name (Legal Business Name): NANCY KAYE ALLEN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 N YELLOW SPRINGS ST
SPRINGFIELD OH
45504-2463
US

IV. Provider business mailing address

474 N YELLOW SPRINGS ST
SPRINGFIELD OH
45504-2463
US

V. Phone/Fax

Practice location:
  • Phone: 937-399-9500
  • Fax: 937-342-4242
Mailing address:
  • Phone: 937-399-9500
  • Fax: 937-342-4242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI 0004148
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: