Healthcare Provider Details

I. General information

NPI: 1992390512
Provider Name (Legal Business Name): CONNIE WEATHERHOLT BSW, LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2021
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 METRO PL N STE 300
DUBLIN OH
43017-5320
US

IV. Provider business mailing address

1241 TOWNSHIP ROAD 1175
ASHLAND OH
44805-1980
US

V. Phone/Fax

Practice location:
  • Phone: 855-289-1722
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2410322
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: