Provider Demographics
NPI:1346759107
Name:DAVIS, ANDREW (MSW, LSW, CCHT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MSW, LSW, CCHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 W LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1047
Mailing Address - Country:US
Mailing Address - Phone:614-441-7333
Mailing Address - Fax:
Practice Address - Street 1:4236 E BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1279
Practice Address - Country:US
Practice Address - Phone:380-201-1315
Practice Address - Fax:740-964-0030
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHS.21064291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid