MEDICARE: COLUMBUS COUNSELING AND PSYCHOLOGICAL SERVICES

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1659585099	OTHER		NPPES
2	1134679459	OTHER		NPPES

General Provider Information

NPI Number	:	1568261519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLUMBUS COUNSELING AND PSYCHOLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 21467
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-0467
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1071 FISHINGER RD STE 102
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-2357
Country	:	US
Telephone Number	:	308-208-1752
Fax Number	:

Authorized Official
Title or Position	:	OWNER/LICENSED PSYCHOLOGIST
Name	:	DR. SCOTT DEATHERAGE
Credential	:	PHD
Telephone Number	:	308-208-1752

Provider Enumeration Date	:	03/12/2025
Last Update Date	:	03/12/2025

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