Healthcare Provider Details

I. General information

NPI: 1306204979
Provider Name (Legal Business Name): CONNIE UNDERWOOD LCDC III
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 07/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 FULTON AVE
CINCINNATI OH
45206
US

IV. Provider business mailing address

3819 SIMPSON AVE
CINCINNATI OH
45227-3642
US

V. Phone/Fax

Practice location:
  • Phone: 513-961-4663
  • Fax:
Mailing address:
  • Phone: 513-304-3467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII161742
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: