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General NPI Number Information
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NPI Number | 1598175010
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Entity Type | Organization
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Legal Business Name | OHIO ARMY NATIONAL GUARD
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Dates
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Enumeration Date | 05/06/2014
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Last Update Date | 05/06/2014
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Provider Practice Location Address
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Address Line | 3990 E BROAD ST DSCC, BUILDING 11, SEC.11
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City | COLUMBUS
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State | OH
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Zip | 43213-1152
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Country | US
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Telephone | 614-336-7393
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Fax |
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Provider Business Mailing Address
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Address Line | 3990 E BROAD ST DSCC, BUILDING 11, SEC.11
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City | COLUMBUS
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State | OH
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Zip | 43213-1152
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CLINICAL THERAPIST/SOCIAL WORKER
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Name | DAVID ISAAC KIRKER
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Credential | LISW
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Telephone | 614-336-7393
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 0900648
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 0922648
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License Number State | OH
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