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NPI Code Detail

MEDICARE: KIRA SUE VAN DER LAAR LISW

MEDICARE: KIRA SUE VAN DER LAAR 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
1101YM0800XMental Health CounselorI.1901397OH

General Provider Information

NPI Number : 1689276263
Entity Type Code : Individual
Provider Name (Legal Business Name) : KIRA SUE VAN DER LAAR LISW
Provider Business Mailing Address
First Line : 400 W MADISON ST
Second Line :
City : GIBSONBURG
State : OH
Zip : 43431-1221
Country : US
Telephone Number : 567-201-6450
Fax Number :
Provider Business Practice Location Address
First Line : 430 N BROADWAY ST
Second Line :
City : GREEN SPRINGS
State : OH
Zip : 44836-9734
Country : US
Telephone Number : 844-534-3638
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/10/2020
Last Update Date : 04/07/2025

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Directions to “ KIRA SUE VAN DER LAAR LISW” Practice Location

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