Provider Demographics
NPI:1124403746
Name:VANAMERONGEN, CORRIE M (LISW)
Entity Type:Individual
Prefix:
First Name:CORRIE
Middle Name:M
Last Name:VANAMERONGEN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 WATERMARK DR
Mailing Address - Street 2:SUITE 420
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1048
Mailing Address - Country:US
Mailing Address - Phone:614-645-5500
Mailing Address - Fax:614-645-5517
Practice Address - Street 1:2300 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43204-3783
Practice Address - Country:US
Practice Address - Phone:614-645-2300
Practice Address - Fax:614-645-2333
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1302873104100000X
OHI.15013461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH433613Medicare PIN
OHH433610Medicare PIN
OHH433616Medicare PIN
OHH433612Medicare PIN
OHH433618Medicare PIN
OHH433615Medicare PIN
OHH433617Medicare PIN
OHH433611Medicare PIN
OHH433614Medicare PIN