Provider Demographics
NPI:1437476322
Name:LUANGISA, GRACE (LSW)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:LUANGISA
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 1:899 E BROAD ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-1156
Mailing Address - Country:US
Mailing Address - Phone:614-355-8000
Mailing Address - Fax:614-355-8018
Practice Address - Street 1:899 E BROAD ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-1156
Practice Address - Country:US
Practice Address - Phone:614-355-8000
Practice Address - Fax:614-355-8018
Is Sole Proprietor?:No
Enumeration Date:2010-05-01
Last Update Date:2010-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0801043104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH08258Medicaid