Provider Demographics
NPI:1598175010
Name:OHIO ARMY NATIONAL GUARD
Entity Type:Organization
Organization Name:OHIO ARMY NATIONAL GUARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST/SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ISAAC
Authorized Official - Last Name:KIRKER
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:614-336-7393
Mailing Address - Street 1:3990 E BROAD ST
Mailing Address - Street 2:DSCC, BUILDING 11, SEC.11
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-1152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3990 E BROAD ST
Practice Address - Street 2:DSCC, BUILDING 11, SEC.11
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-1152
Practice Address - Country:US
Practice Address - Phone:614-336-7393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0900648251B00000X
OH0922648251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management