Basic Information
| Provider Information | |||||||||
| NPI: | 1730230343 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY FOR NEW DIRECTION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2096 W MOUND ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432232021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142721464 | ||||||||
| FaxNumber: | 6142721486 | ||||||||
| Practice Location | |||||||||
| Address1: | 2096 W MOUND ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432232021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142721464 | ||||||||
| FaxNumber: | 6142721486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2007 | ||||||||
| LastUpdateDate: | 03/01/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JEFFERSON | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6142721464 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | OCPS II LICDC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | 251B00000X | OH | N | Agencies | Case Management | 251S00000X | 13316 | OH | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 101Y00000X | 01 | OH | SOCIAL WORK | OTHER |