MEDICARE: ANXIETY AND STRESS DISORDERS CLINIC

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	103TC0700X	Clinical Psychologist	5678	OH

General Provider Information

NPI Number	:	1376713289
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANXIETY AND STRESS DISORDERS CLINIC

Provider Business Mailing Address
First Line	:	1835 NEIL AVE
Second Line	:	105 PSYCHOLOGY BUILDING
City	:	COLUMBUS
State	:	OH
Zip	:	43210-1351
Country	:	US
Telephone Number	:	614-292-9484
Fax Number	:	614-292-4539

Provider Business Practice Location Address
First Line	:	1835 NEIL AVE
Second Line	:	105 PSYCHOLOGY BUILDING
City	:	COLUMBUS
State	:	OH
Zip	:	43210-1351
Country	:	US
Telephone Number	:	614-292-9484
Fax Number	:	614-292-4539

Authorized Official
Title or Position	:	DIRECTOR OF CLINICAL SERVICES
Name	:	DR. JOSEPH PHILIP DECOLA
Credential	:	PH.D.
Telephone Number	:	614-292-9484

Provider Enumeration Date	:	03/06/2008
Last Update Date	:	06/17/2008

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