Healthcare Provider Details

I. General information

NPI: 1326774753
Provider Name (Legal Business Name): ABBY MARIE BAULD LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 ROYAL WOOD CT
VANDALIA OH
45377-1800
US

IV. Provider business mailing address

320 ROYAL WOOD CT
VANDALIA OH
45377-1800
US

V. Phone/Fax

Practice location:
  • Phone: 937-654-6209
  • Fax:
Mailing address:
  • Phone: 937-654-6209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2005661
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: