Provider Demographics
NPI:1114291432
Name:FODOR-NAGY, MIRELA (PCC)
Entity Type:Individual
Prefix:MRS
First Name:MIRELA
Middle Name:
Last Name:FODOR-NAGY
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:MISS
Other - First Name:MIRELA
Other - Middle Name:
Other - Last Name:BORDEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MHC
Mailing Address - Street 1:4801 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-7901
Mailing Address - Country:US
Mailing Address - Phone:347-531-4099
Mailing Address - Fax:
Practice Address - Street 1:399 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5384
Practice Address - Country:US
Practice Address - Phone:614-355-8550
Practice Address - Fax:614-355-8593
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP79833101YM0800X
OHE1300022101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid