Healthcare Provider Details

I. General information

NPI: 1629428974
Provider Name (Legal Business Name): MEDOPTIONS OF OHIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 DUBLIN RD STE 400
COLUMBUS OH
43215-1052
US

IV. Provider business mailing address

PO BOX 1595
MIDDLETOWN CT
06457-8095
US

V. Phone/Fax

Practice location:
  • Phone: 860-788-6404
  • Fax:
Mailing address:
  • Phone: 860-788-6404
  • Fax: 860-829-0495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREA GODFREY
Title or Position: CREDENTIALING & ENROLLMENT MANAGER
Credential:
Phone: 860-398-6441