Provider Demographics
NPI:1376959551
Name:LITTLE, MICHAELA MB (LISW-S)
Entity Type:Individual
Prefix:MS
First Name:MICHAELA
Middle Name:MB
Last Name:LITTLE
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8479 S MASON MONTGOMERY RD STE 4
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-4023
Mailing Address - Country:US
Mailing Address - Phone:513-445-8393
Mailing Address - Fax:513-725-1141
Practice Address - Street 1:8479 S MASON MONTGOMERY RD STE 4
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-4023
Practice Address - Country:US
Practice Address - Phone:513-445-8393
Practice Address - Fax:513-725-1141
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-08
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6405-S104100000X
OHI.1201090-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0172131Medicaid