=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265923452
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRONT STREET ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2018
-----------------------------------------------------
Last Update Date | 06/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 987 S HIGH ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-468-8184
-----------------------------------------------------
Fax | 614-681-0546
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 987 S HIGH ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43206-2527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-468-8184
-----------------------------------------------------
Fax | 614-681-0546
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CHAD CORBLEY
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 614-370-4549
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------