Healthcare Provider Details

I. General information

NPI: 1063230175
Provider Name (Legal Business Name): I AM BOUNDLESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 E DUBLIN GRANVILLE RD STE H
WORTHINGTON OH
43085-3192
US

IV. Provider business mailing address

445 E DUBLIN GRANVILLE RD STE H
WORTHINGTON OH
43085-3192
US

V. Phone/Fax

Practice location:
  • Phone: 614-844-3800
  • Fax: 614-515-5779
Mailing address:
  • Phone: 614-844-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: LAURIE B HICKMAN
Title or Position: CONTRACTING & CREDENTIALING MANAGER
Credential:
Phone: 614-844-3800