1376713289 NPI number — ANXIETY AND STRESS DISORDERS CLINIC

Table of content: (NPI 1376713289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376713289 NPI number — ANXIETY AND STRESS DISORDERS CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANXIETY AND STRESS DISORDERS CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376713289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1835 NEIL AVE
Provider Second Line Business Mailing Address:
105 PSYCHOLOGY BUILDING
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43210-1351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-292-9484
Provider Business Mailing Address Fax Number:
614-292-4539

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1835 NEIL AVE
Provider Second Line Business Practice Location Address:
105 PSYCHOLOGY BUILDING
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43210-1351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
614-292-9484
Provider Business Practice Location Address Fax Number:
614-292-4539
Provider Enumeration Date:
03/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DECOLA
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
PHILIP
Authorized Official Title or Position:
DIRECTOR OF CLINICAL SERVICES
Authorized Official Telephone Number:
614-292-9484

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  5678 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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