Basic Information
| Provider Information | |||||||||
| NPI: | 1396171534 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MFT, PC-CR, CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1490 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142520731 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1490 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142520731 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2013 | ||||||||
| LastUpdateDate: | 09/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA130496-PRE | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | C.1100596 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | M.1300007 | OH | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.