Basic Information
| Provider Information | |||||||||
| NPI: | 1588179394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONSOLO | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4625 MORSE RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | GAHANNA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432308355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373999500 | ||||||||
| FaxNumber: | 9373424242 | ||||||||
| Practice Location | |||||||||
| Address1: | 474 N YELLOW SPRINGS ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 455042463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373999500 | ||||||||
| FaxNumber: | 9373424242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2017 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | S.1701582 | OH | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | I.2002083 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.