Provider Demographics
NPI:1588179394
Name:CONSOLO, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:CONSOLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4625 MORSE RD
Mailing Address - Street 2:STE 200
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-8355
Mailing Address - Country:US
Mailing Address - Phone:937-399-9500
Mailing Address - Fax:937-342-4242
Practice Address - Street 1:474 N YELLOW SPRINGS ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-2463
Practice Address - Country:US
Practice Address - Phone:937-399-9500
Practice Address - Fax:937-342-4242
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1701582104100000X
OHI.20020831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker