MEDICARE: KATRINA CONNELL 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	166548	OH
2	104100000X	Social Worker	S.1903328	OH
3	104100000X	Social Worker	I.2304605	OH
4	405300000X	Prevention Professional	161761	OH
5	1041C0700X	Clinical Social Worker	I.2304605	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346728714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATRINA CONNELL LISW

Provider Business Mailing Address
First Line	:	5563 FAR HILLS AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45429-2225
Country	:	US
Telephone Number	:	937-291-2300
Fax Number	:	937-291-2303

Provider Business Practice Location Address
First Line	:	5563 FAR HILLS AVE
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45429-2225
Country	:	US
Telephone Number	:	937-291-2300
Fax Number	:	937-291-2303

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

Provider Enumeration Date	:	07/30/2018
Last Update Date	:	03/22/2024

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Directions to “ KATRINA CONNELL LISW” Practice Location

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