MEDICARE: ELIZABETH JOY LSW, LCDC III

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	101YM0800X	Mental Health Counselor	S0900572	OH

General Provider Information

NPI Number	:	1417300914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH JOY LSW, LCDC III

Provider Business Mailing Address
First Line	:	PO BOX 215
Second Line	:
City	:	BLACKLICK
State	:	OH
Zip	:	43004-0215
Country	:	US
Telephone Number	:	614-332-1592
Fax Number	:

Provider Business Practice Location Address
First Line	:	665 E DUBLIN GRANVILLE RD
Second Line	:	#300
City	:	COLUMBUS
State	:	OH
Zip	:	43229-3245
Country	:	US
Telephone Number	:	614-846-6265
Fax Number	:

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

Provider Enumeration Date	:	07/20/2016
Last Update Date	:	07/20/2016

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