Provider Demographics
NPI:1417473232
Name:FORTNER, ASIA MARIE (CDCA)
Entity Type:Individual
Prefix:MS
First Name:ASIA
Middle Name:MARIE
Last Name:FORTNER
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 NOE BIXBY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1460
Mailing Address - Country:US
Mailing Address - Phone:614-892-2454
Mailing Address - Fax:614-892-2459
Practice Address - Street 1:100 NOE BIXBY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1460
Practice Address - Country:US
Practice Address - Phone:614-892-2454
Practice Address - Fax:614-892-2459
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.164075101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)