Basic Information
| Provider Information | |||||||||
| NPI: | 1023443082 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEA GORDON | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW, LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1751 E LONG ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432032045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142538050 | ||||||||
| FaxNumber: | 6142538066 | ||||||||
| Practice Location | |||||||||
| Address1: | 1751 E LONG ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432032045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142538050 | ||||||||
| FaxNumber: | 6142538066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2013 | ||||||||
| LastUpdateDate: | 12/04/2017 | ||||||||
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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 | 1041C0700X | I.1600781 | OH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | S.0023418 | OH | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | JSG1022 | 05 | OH | MEDICAID |