Healthcare Provider Details

I. General information

NPI: 1629784756
Provider Name (Legal Business Name): ABIGAIL GRACE PENHORWOOD CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1791 ALUM CREEK DR
COLUMBUS OH
43207-1757
US

IV. Provider business mailing address

1791 ALUM CREEK DR
COLUMBUS OH
43207-1757
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.182682
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number182682
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: