Provider Demographics
NPI:1356850192
Name:BUBECK, ALISA E (SWA)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:E
Last Name:BUBECK
Suffix:
Gender:F
Credentials:SWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-1944
Mailing Address - Country:US
Mailing Address - Phone:937-547-7330
Mailing Address - Fax:937-547-7329
Practice Address - Street 1:600 WALNUT ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1944
Practice Address - Country:US
Practice Address - Phone:937-547-7330
Practice Address - Fax:937-547-7329
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHW.1000002171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator