MEDICARE: THE GAP INITIATIVE

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	106H00000X	Marriage & Family Therapist	1700380	OH

General Provider Information

NPI Number	:	1558889782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE GAP INITIATIVE

Provider Business Mailing Address
First Line	:	6596 QUAIL CREEK DR
Second Line	:
City	:	CANAL WINCHESTER
State	:	OH
Zip	:	43110-9394
Country	:	US
Telephone Number	:	614-327-0535
Fax Number	:

Provider Business Practice Location Address
First Line	:	1611 OLD LEONARD AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43219-2597
Country	:	US
Telephone Number	:	614-327-0535
Fax Number	:

Authorized Official
Title or Position	:	SOCIAL WORKER
Name	:	LAURA I DAVIS
Credential	:	LISW
Telephone Number	:	614-586-3830

Provider Enumeration Date	:	09/08/2017
Last Update Date	:	09/08/2017

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Directions to “THE GAP INITIATIVE ” Practice Location

Language	Start Address	Practice Location

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