Provider Demographics
NPI:1639626914
Name:PURDOM, STEPHANIE (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PURDOM
Suffix:
Gender:F
Credentials:LCSW
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 STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43230-8355
Mailing Address - Country:US
Mailing Address - Phone:630-404-7833
Mailing Address - Fax:855-259-2615
Practice Address - Street 1:4625 MORSE RD STE 200
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-8355
Practice Address - Country:US
Practice Address - Phone:614-383-8381
Practice Address - Fax:855-259-2615
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-05
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490187461041C0700X
OHI.19015231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical