Basic Information
| Provider Information | |||||||||
| NPI: | 1558889782 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE GAP INITIATIVE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6596 QUAIL CREEK DR | ||||||||
| Address2: | |||||||||
| City: | CANAL WINCHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431109394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143270535 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1611 OLD LEONARD AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432192597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143270535 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2017 | ||||||||
| LastUpdateDate: | 09/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | LAURA | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 6145863830 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LISW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 1700380 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.