Basic Information
| Provider Information | |||||||||
| NPI: | 1144881244 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOTTHARDT | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 445 E DUBLIN GRANVILLE RD | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430853192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148443800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 445 E DUBLIN GRANVILLE RD STE G | ||||||||
| Address2: | |||||||||
| City: | WORTHINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430853183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148443800 | ||||||||
| FaxNumber: | 6145155779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2019 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | RBT-19-81711 | 01 | RBT CERTIFICATE | OTHER |