Provider Demographics
NPI:1912553512
Name:GUILL, LIZA MAE
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:MAE
Last Name:GUILL
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 1:268 WOOD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2222
Mailing Address - Country:US
Mailing Address - Phone:419-689-7035
Mailing Address - Fax:
Practice Address - Street 1:1033 LARCHWOOD RD
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44907-2424
Practice Address - Country:US
Practice Address - Phone:419-747-4122
Practice Address - Fax:419-747-4126
Is Sole Proprietor?:No
Enumeration Date:2019-08-11
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician