Provider Demographics
NPI:1053550129
Name:LOCKE-PORRECA, ROSA LINDA (LISW)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:LINDA
Last Name:LOCKE-PORRECA
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636930
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6930
Mailing Address - Country:US
Mailing Address - Phone:800-514-4390
Mailing Address - Fax:440-808-3676
Practice Address - Street 1:770 W HIGH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-3990
Practice Address - Country:US
Practice Address - Phone:419-996-5033
Practice Address - Fax:419-996-5266
Is Sole Proprietor?:No
Enumeration Date:2009-02-13
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0009012-SUPV104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHLOSW35331Medicare PIN