Provider Demographics
NPI:1073009395
Name:KOLESAR, LAINE (LSW)
Entity Type:Individual
Prefix:
First Name:LAINE
Middle Name:
Last Name:KOLESAR
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 DILLON AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45208-4209
Mailing Address - Country:US
Mailing Address - Phone:513-562-7534
Mailing Address - Fax:
Practice Address - Street 1:431 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-4004
Practice Address - Country:US
Practice Address - Phone:614-885-5020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1802707104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3082515Medicaid