Basic Information
| Provider Information | |||||||||
| NPI: | 1942585989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEROLD | ||||||||
| FirstName: | REBEKAH | ||||||||
| MiddleName: | IREAN | ||||||||
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| Credential: | MSW, LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 715194 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432715194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558004 | ||||||||
| FaxNumber: | 6143550509 | ||||||||
| Practice Location | |||||||||
| Address1: | 6435 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432131507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558160 | ||||||||
| FaxNumber: | 6143558180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2011 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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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 | S0600039 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 08258 | 05 | OH | MEDICAID |