Basic Information
| Provider Information | |||||||||
| NPI: | 1417555228 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOMMERS | ||||||||
| FirstName: | DESHAWNA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1801 WATERMARK DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432157088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144878875 | ||||||||
| FaxNumber: | 6144878759 | ||||||||
| Practice Location | |||||||||
| Address1: | 1303 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432052047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142526927 | ||||||||
| FaxNumber: | 6142524367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2020 | ||||||||
| LastUpdateDate: | 10/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1679721906 | 05 | OH | MEDICAID |