Basic Information
| Provider Information | |||||||||
| NPI: | 1275806879 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANSICKLE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 WATERMARK DR | ||||||||
| Address2: | STE 200 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432157088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882022965 | ||||||||
| FaxNumber: | 6144878769 | ||||||||
| Practice Location | |||||||||
| Address1: | 527 S HIGH ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432155602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664386508 | ||||||||
| FaxNumber: | 6142279445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2012 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 1041C0700X | I.1303572-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 104100000X | S.0901492 | OH | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.