Basic Information
| Provider Information | |||||||||
| NPI: | 1457705907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLURE | ||||||||
| FirstName: | ELIZABETH ANNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 CINCINNATI BATAVIA PIKE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452441557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137521555 | ||||||||
| FaxNumber: | 5137532144 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 CINCINNATI BATAVIA PIKE | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452441557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137521555 | ||||||||
| FaxNumber: | 5137532144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2016 | ||||||||
| LastUpdateDate: | 04/21/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | C.1300348 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | C.1300348 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 2846595 | 05 | OH | MEDICAID |