Basic Information
Provider Information | |||||||||
NPI: | 1669542643 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NATIONWIDE CHILDREN'S HOSPITAL ,INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NATIONWIDE CHILDREN'S HOSPITAL BEHAVIORAL HEALTH SERVICES | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 255 E MAIN ST | ||||||||
Address2: | 3RD FLOOR | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432155222 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6143558004 | ||||||||
FaxNumber: | 6143550509 | ||||||||
Practice Location | |||||||||
Address1: | 495 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432155349 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6143558005 | ||||||||
FaxNumber: | 6143558030 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/08/2006 | ||||||||
LastUpdateDate: | 07/27/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HOFFMAN | ||||||||
AuthorizedOfficialFirstName: | AILEEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BEHAVIORAL HEALTH OPERATIONS MANAGE | ||||||||
AuthorizedOfficialTelephone: | 6143550511 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QM0801X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.