Healthcare Provider Details

I. General information

NPI: 1427087667
Provider Name (Legal Business Name): CAROL A BLINE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CAROL B MANOSH PH.D.

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 MORSE RD STE 201
GAHANNA OH
43230-7300
US

IV. Provider business mailing address

7727 AUSTINBURG RD
ASHTABULA OH
44004-9010
US

V. Phone/Fax

Practice location:
  • Phone: 614-578-1165
  • Fax: 614-388-5561
Mailing address:
  • Phone: 614-578-1185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number5339
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number5339
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5339
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number5339
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number5339
License Number StateOH
# 6
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5339
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: