Healthcare Provider Details

I. General information

NPI: 1316501513
Provider Name (Legal Business Name): PAMELA CORNLEY CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1791 ALUM CREEK DR
COLUMBUS OH
43207-1757
US

IV. Provider business mailing address

1515 E BROAD ST
COLUMBUS OH
43205-1550
US

V. Phone/Fax

Practice location:
  • Phone: 614-445-8131
  • Fax:
Mailing address:
  • Phone: 614-569-7736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.177204
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: