Healthcare Provider Details

I. General information

NPI: 1225512445
Provider Name (Legal Business Name): YOLANDA CEMORA FAIRFAX LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6173 NORTHBEND DR
CANAL WINCHESTER OH
43110-9133
US

IV. Provider business mailing address

5310 E MAIN ST
COLUMBUS OH
43213-2598
US

V. Phone/Fax

Practice location:
  • Phone: 614-751-1090
  • Fax: 614-751-1091
Mailing address:
  • Phone: 614-751-1090
  • Fax: 614-751-1091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1200495
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: