Provider Demographics
NPI:1780137950
Name:MISRA, KIERSTEN (MSW, LISW-S, LICDC)
Entity type:Individual
Prefix:
First Name:KIERSTEN
Middle Name:
Last Name:MISRA
Suffix:
Gender:F
Credentials:MSW, LISW-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 EXECUTIVE PKWY STE 205
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-1327
Mailing Address - Country:US
Mailing Address - Phone:419-360-7026
Mailing Address - Fax:419-482-1262
Practice Address - Street 1:3131 EXECUTIVE PKWY STE 205
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-1327
Practice Address - Country:US
Practice Address - Phone:419-360-7026
Practice Address - Fax:419-482-1262
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-25
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.161602101YA0400X
OHI.1801351-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0360500Medicaid
OH1972140044OtherNPI II