Healthcare Provider Details

I. General information

NPI: 1770023343
Provider Name (Legal Business Name): ANDREA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2017
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 LONDON GROVEPORT RD
GROVE CITY OH
43123-8700
US

IV. Provider business mailing address

2690 BILLINGSLEY RD
COLUMBUS OH
43235-1924
US

V. Phone/Fax

Practice location:
  • Phone: 614-766-0161
  • Fax: 614-766-0298
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE.1700090
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: