Basic Information
| Provider Information | |||||||||
| NPI: | 1003154410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILBERT | ||||||||
| FirstName: | LARYSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.S., LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 277 QUAIL HAVEN DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432355652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143090677 | ||||||||
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| Practice Location | |||||||||
| Address1: | 299 CRAMER CREEK CT | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430172586 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148895722 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2013 | ||||||||
| LastUpdateDate: | 02/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | C.1200655-TRNE | OH | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | C.1200655 | OH | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | E.1901044 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1003154410 | 05 | OH | MEDICAID |