Basic Information
| Provider Information | |||||||||
| NPI: | 1538673371 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | CATHERINE | ||||||||
| MiddleName: | ELISE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALLENBROCK | ||||||||
| OtherFirstName: | CATHERINE | ||||||||
| OtherMiddleName: | ELISE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1421 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432161421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147530836 | ||||||||
| FaxNumber: | 6143893841 | ||||||||
| Practice Location | |||||||||
| Address1: | 6400 E BROAD ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432132086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6146553345 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2017 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | C.1700519 | OH | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | C.1700519 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.