1568797439 NPI number — JILL MARIE MYSONHIMER LISW-SUPV

Table of content: JILL MARIE MYSONHIMER LISW-SUPV (NPI 1568797439)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568797439 NPI number — JILL MARIE MYSONHIMER LISW-SUPV

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MYSONHIMER
Provider First Name:
JILL
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LISW-SUPV
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCINTOSH
Provider Other First Name:
JILL
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LISW-SUPV
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1568797439
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 COOK RD
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45036-9600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-228-7800
Provider Business Mailing Address Fax Number:
513-695-2952

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
975 KINGSVIEW DR
Provider Second Line Business Practice Location Address:
BLDG A
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45036-9562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-228-7800
Provider Business Practice Location Address Fax Number:
513-228-7846
Provider Enumeration Date:
10/12/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  I-1101601-SUPV , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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