Provider Demographics
NPI:1942791884
Name:VIERSTRA, CYRIL (LSW)
Entity Type:Individual
Prefix:
First Name:CYRIL
Middle Name:
Last Name:VIERSTRA
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:CY
Other - Middle Name:
Other - Last Name:NO LAST NAME
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LSW
Mailing Address - Street 1:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43216-1595
Mailing Address - Country:US
Mailing Address - Phone:800-321-8293
Mailing Address - Fax:
Practice Address - Street 1:314 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MC ARTHUR
Practice Address - State:OH
Practice Address - Zip Code:45651
Practice Address - Country:US
Practice Address - Phone:800-321-8293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-26
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1000888104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker