=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376054312
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY COUNSELING & CONSULTATION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2017
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4701 OLENTANGY RIVER RD STE 3
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43214-1939
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-321-9298
-----------------------------------------------------
Fax | 614-437-4075
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4840 LOBLOLLY DR
-----------------------------------------------------
City | CANAL WINCHESTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43110-7010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-321-9298
-----------------------------------------------------
Fax | 614-437-4075
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OPERATOR
-----------------------------------------------------
Name | MICHELLE CHERI JONES
-----------------------------------------------------
Credential | MSW, LISW, LICDC
-----------------------------------------------------
Telephone | 614-432-4988
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | I.1700314
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------