Provider Demographics
NPI:1194230797
Name:KINNINGER, LISAMARIE
Entity Type:Individual
Prefix:
First Name:LISAMARIE
Middle Name:
Last Name:KINNINGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1946 N 13TH ST STE 450
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7257
Mailing Address - Country:US
Mailing Address - Phone:419-720-6811
Mailing Address - Fax:
Practice Address - Street 1:1946 N 13TH ST STE 450
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-7257
Practice Address - Country:US
Practice Address - Phone:419-708-1875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.166152101YA0400X
171M00000X
OH162204171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0300394Medicaid