Basic Information
Provider Information | |||||||||
NPI: | 1114291432 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FODOR-NAGY | ||||||||
FirstName: | MIRELA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PCC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BORDEA | ||||||||
OtherFirstName: | MIRELA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MHC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4801 RIVERSIDE DR | ||||||||
Address2: |   | ||||||||
City: | DELAWARE | ||||||||
State: | OH | ||||||||
PostalCode: | 430157901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3475314099 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 399 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432155384 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6143558550 | ||||||||
FaxNumber: | 6143558593 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/05/2012 | ||||||||
LastUpdateDate: | 05/22/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | P79833 | NY | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | E1300022 | OH | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
ID | Type | State | Issuer | Description | 2846675 | 05 | OH |   | MEDICAID |