=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528498730
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY DAHL MSW, LSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2013
-----------------------------------------------------
Last Update Date | 08/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 CHILDRENS DR
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43205-2664
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-722-6300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3292 N EVERGREEN DR NE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-9746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-722-6300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 1000903
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------