Healthcare Provider Details

I. General information

NPI: 1669146056
Provider Name (Legal Business Name): LIAH JUTILA MSW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2021
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 MAIN ST W STE 304
ASHLAND WI
54806-1579
US

IV. Provider business mailing address

49 HONEY HILL LN
RAYMOND ME
04071-7307
US

V. Phone/Fax

Practice location:
  • Phone: 218-461-8414
  • Fax:
Mailing address:
  • Phone: 815-509-8304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number132395-121
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11098-123
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC22268
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: