Healthcare Provider Details

I. General information

NPI: 1447832415
Provider Name (Legal Business Name): CYNTHIA BOBO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 N GRANT AVE
COLUMBUS OH
43215-2855
US

IV. Provider business mailing address

507 W FRONT ST APT 3
LOGAN OH
43138-1638
US

V. Phone/Fax

Practice location:
  • Phone: 740-877-5055
  • Fax:
Mailing address:
  • Phone: 740-870-7531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.180958
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: