Healthcare Provider Details

I. General information

NPI: 1811410210
Provider Name (Legal Business Name): KRISTINA L EDLER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 07/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 RIVERSIDE DR STE 206
UPPER ARLINGTON OH
43221-2550
US

IV. Provider business mailing address

2718 MOUNT HOLYOKE RD
COLUMBUS OH
43221-3425
US

V. Phone/Fax

Practice location:
  • Phone: 614-209-1234
  • Fax:
Mailing address:
  • Phone: 614-209-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberI.1451189
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberI.1451189
License Number StateOH

VIII. Authorized Official

Name: KRISTINA L EDLER
Title or Position: CLINICAL THERAPIST
Credential: LISWS
Phone: 614-209-1234