Healthcare Provider Details

I. General information

NPI: 1821853029
Provider Name (Legal Business Name): ELISA REBECCA KIBBEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2024
Last Update Date: 05/22/2026
Certification Date: 05/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1791 ALUM CREEK DR
COLUMBUS OH
43207-1708
US

IV. Provider business mailing address

726 WAGER ST
COLUMBUS OH
43206-1451
US

V. Phone/Fax

Practice location:
  • Phone: 614-353-9568
  • Fax:
Mailing address:
  • Phone: 614-353-9568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2512119
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: