Provider Demographics
NPI:1023553518
Name:DILLARD, ALISA MONIQUE (LSW)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:MONIQUE
Last Name:DILLARD
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2140
Mailing Address - Country:US
Mailing Address - Phone:614-516-5430
Mailing Address - Fax:614-252-8468
Practice Address - Street 1:1490 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2140
Practice Address - Country:US
Practice Address - Phone:614-516-5430
Practice Address - Fax:614-252-8468
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0700852104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker