Provider Demographics
NPI:1306204979
Name:UNDERWOOD, CONNIE (LCDC III)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:LCDC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3819 SIMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-3642
Mailing Address - Country:US
Mailing Address - Phone:513-304-3467
Mailing Address - Fax:
Practice Address - Street 1:2211 FULTON AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206
Practice Address - Country:US
Practice Address - Phone:513-961-4663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-10
Last Update Date:2018-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII161742101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)