Basic Information
| Provider Information | |||||||||
| NPI: | 1962466714 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YEAGER | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1670 UPHAM DR. | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432101250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142939600 | ||||||||
| FaxNumber: | 6142939467 | ||||||||
| Practice Location | |||||||||
| Address1: | 1670 UPHAM DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432101250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142939600 | ||||||||
| FaxNumber: | 6142939467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 10/20/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 882503 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 1-0009214 | OH | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.