Healthcare Provider Details

I. General information

NPI: 1205695160
Provider Name (Legal Business Name): CARDELIA DENISE SHANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2024
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LAKE CLUB DR
COLUMBUS OH
43232-3204
US

IV. Provider business mailing address

900 S WASHINGTON AVE APT B
COLUMBUS OH
43206-2350
US

V. Phone/Fax

Practice location:
  • Phone: 614-704-5224
  • Fax: 614-515-2693
Mailing address:
  • Phone: 220-228-1386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: