=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578030979
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ACACIA QUAINTANCE LISW-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2018
-----------------------------------------------------
Last Update Date | 07/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1069 W BROAD ST STE 1008
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43222-1440
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-681-1460
-----------------------------------------------------
Fax | 614-639-8228
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5587 READERS ST
-----------------------------------------------------
City | CANAL WINCHESTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43110-8328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | I.1801256
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------