Basic Information
| Provider Information | |||||||||
| NPI: | 1003350448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRAIG | ||||||||
| FirstName: | ETHAN | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1865 BEALER DR APT G | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433028764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403619098 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1199 DELAWARE AVE STE 107 | ||||||||
| Address2: | 195 N GRANT AVE, COLUMBUS, OH 43215 | ||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8885229174 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2016 | ||||||||
| LastUpdateDate: | 05/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1903694 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 1003350448 | 05 | OH | MEDICAID |