Basic Information
| Provider Information | |||||||||
| NPI: | 1194230797 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KINNINGER | ||||||||
| FirstName: | LISAMARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1946 N 13TH ST STE 450 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436047257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197206811 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1946 N 13TH ST STE 450 | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436047257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197081875 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2017 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.166152 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 0300394 | 05 | OH | MEDICAID |