MEDICARE: ANDREW COLVIN, PH.D., LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center	5319	OH

General Provider Information

NPI Number	:	1023254927
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANDREW COLVIN, PH.D., LLC

Provider Business Mailing Address
First Line	:	7650 RIVERS EDGE DR STE 140
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43235-1342
Country	:	US
Telephone Number	:	614-430-9870
Fax Number	:

Provider Business Practice Location Address
First Line	:	7650 RIVERS EDGE DR STE 140
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43235-1342
Country	:	US
Telephone Number	:	614-430-9870
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ANDREW NEIL COLVIN
Credential	:	PH.D.
Telephone Number	:	614-430-9870

Provider Enumeration Date	:	12/23/2008
Last Update Date	:	12/23/2008

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