Healthcare Provider Details

I. General information

NPI: 1417417411
Provider Name (Legal Business Name): MICKI CHURCH LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 01/27/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 PARSONS AVE
COLUMBUS OH
43206-2345
US

IV. Provider business mailing address

328 N BURGESS AVE
COLUMBUS OH
43204-3308
US

V. Phone/Fax

Practice location:
  • Phone: 614-674-6085
  • Fax:
Mailing address:
  • Phone: 614-601-0359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2208303
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: