Healthcare Provider Details

I. General information

NPI: 1295473338
Provider Name (Legal Business Name): AVIANNA SIMONE VIGIL LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2022
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1791 ALUM CREEK DR
COLUMBUS OH
43207-1757
US

IV. Provider business mailing address

1430 S HIGH ST
COLUMBUS OH
43207-1045
US

V. Phone/Fax

Practice location:
  • Phone: 614-460-1105
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2207495
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: