Healthcare Provider Details

I. General information

NPI: 1134657414
Provider Name (Legal Business Name): VANESSA REBOLLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 DENNISON AVE STE 101
COLUMBUS OH
43201-3497
US

IV. Provider business mailing address

PO BOX 78000
DETROIT MI
48278-1625
US

V. Phone/Fax

Practice location:
  • Phone: 614-674-6076
  • Fax:
Mailing address:
  • Phone: 614-355-8004
  • Fax: 614-355-2220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.2404730
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.2404730
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberC1600658TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: