=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629182225
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA ELIZABETH WAGNER LISW-S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2006
-----------------------------------------------------
Last Update Date | 04/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 W ESPY ST
-----------------------------------------------------
City | KENTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43326-2117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-679-5994
-----------------------------------------------------
Fax | 419-225-8878
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 329 N WEST ST
-----------------------------------------------------
City | LIMA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45801-4332
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-221-3072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I.0009675-SUPV
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------