Healthcare Provider Details

I. General information

NPI: 1679291926
Provider Name (Legal Business Name): MS. COURTNEY SAMANTHA PHELPS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2022
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 W WILSON BRIDGE RD STE 350
WORTHINGTON OH
43085-5220
US

IV. Provider business mailing address

7100 GRAPHICS WAY STE 3100
LEWIS CENTER OH
43035-1123
US

V. Phone/Fax

Practice location:
  • Phone: 614-245-5119
  • Fax:
Mailing address:
  • Phone: 740-428-0428
  • Fax: 740-909-4077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM.2300339-TRNE
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: