Basic Information
| Provider Information | |||||||||
| NPI: | 1336730696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LISATH | ||||||||
| FirstName: | ALEXUS | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 GERVAIS RD | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN FURNACE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456298742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402597000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 303 GERVAIS RD | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN FURNACE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456298742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402597000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2021 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | 101YA0400X | 176336 | OH | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | 176336 | OH | N | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.