Basic Information
| Provider Information | |||||||||
| NPI: | 1033675913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHINN | ||||||||
| FirstName: | ELIZABETH | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 781625 PO BOX 78000 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558004 | ||||||||
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| Practice Location | |||||||||
| Address1: | 495 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432155349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558055 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2019 | ||||||||
| LastUpdateDate: | 07/30/2019 | ||||||||
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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 | 390200000X | S.1700305-TRNE | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041S0200X | S.1903550 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | School |
ID Information
| ID | Type | State | Issuer | Description | 1473276 | 05 | OH | MEDICAID |