Provider Demographics
NPI:1407101801
Name:WARE, MARY ELISE (PC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELISE
Last Name:WARE
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 S FRONT ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-1905
Mailing Address - Country:US
Mailing Address - Phone:614-563-2810
Mailing Address - Fax:
Practice Address - Street 1:761 S FRONT ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206-1905
Practice Address - Country:US
Practice Address - Phone:614-563-2810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-21
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.013669225700000X
OHC.1100290101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist