Healthcare Provider Details

I. General information

NPI: 1962466714
Provider Name (Legal Business Name): KENNETH R YEAGER LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 UPHAM DR
COLUMBUS OH
43210-1250
US

IV. Provider business mailing address

1670 UPHAM DR.
COLUMBUS OH
43210-1250
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-9600
  • Fax: 614-293-9467
Mailing address:
  • Phone: 614-293-9600
  • Fax: 614-293-9467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number882503
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1-0009214
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: