Healthcare Provider Details

I. General information

NPI: 1124403746
Provider Name (Legal Business Name): CORRIE M. VANAMERONGEN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 W BROAD ST
COLUMBUS OH
43204-3783
US

IV. Provider business mailing address

1800 WATERMARK DR SUITE 420
COLUMBUS OH
43215-1048
US

V. Phone/Fax

Practice location:
  • Phone: 614-645-2300
  • Fax: 614-645-2333
Mailing address:
  • Phone: 614-645-5500
  • Fax: 614-645-5517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.1302873
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1501346
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: