Basic Information
| Provider Information | |||||||||
| NPI: | 1861065880 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORDJADZE | ||||||||
| FirstName: | LAURA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1565 BETHEL RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432202005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144593003 | ||||||||
| FaxNumber: | 6144593004 | ||||||||
| Practice Location | |||||||||
| Address1: | 1565 BETHEL RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432202005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144593003 | ||||||||
| FaxNumber: | 6144593004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2021 | ||||||||
| LastUpdateDate: | 07/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C.1902313 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | C.1902313 | 01 | OH | NO INSURER AGREEMENTS | OTHER |