MEDICARE: MRS. NANCY LOUISE GOSZTYLA LISW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	I-5579	OH
2	104100000X	Social Worker	I- 005579	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	I.0005579-SUPV	OTHER	OH	STATE LICENSE

General Provider Information

NPI Number	:	1174805105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NANCY LOUISE GOSZTYLA LISW

Provider Business Mailing Address
First Line	:	1485 BORROR RD
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-8972
Country	:	US
Telephone Number	:	614-801-9568
Fax Number	:

Provider Business Practice Location Address
First Line	:	44 S SOUDER AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43222-1535
Country	:	US
Telephone Number	:	574-546-1900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2011
Last Update Date	:	03/13/2024

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