Healthcare Provider Details

I. General information

NPI: 1629696877
Provider Name (Legal Business Name): TAYLOR THARP LISW-S, LICDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2020
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 BILLINGSLEY RD
COLUMBUS OH
43235-5978
US

IV. Provider business mailing address

10359 HINTON MILL RD
MARYSVILLE OH
43040-8657
US

V. Phone/Fax

Practice location:
  • Phone: 614-738-8646
  • Fax:
Mailing address:
  • Phone: 614-738-8646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC.161778
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1700614-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: