Healthcare Provider Details

I. General information

NPI: 1194272591
Provider Name (Legal Business Name): CARLY HABENSCHUSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 09/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 E. MAIN ST.
COLUMBUS OH
43215
US

IV. Provider business mailing address

DEPT. 781625
DETROIT MI
48278-1625
US

V. Phone/Fax

Practice location:
  • Phone: 614-355-8550
  • Fax: 614-355-8593
Mailing address:
  • Phone: 614-355-8004
  • Fax: 614-355-2220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.1500659
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberC.1500659TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: