Provider Demographics
NPI:1659093615
Name:CHONGSIRIWATANA, YUMIKO
Entity Type:Individual
Prefix:
First Name:YUMIKO
Middle Name:
Last Name:CHONGSIRIWATANA
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 1:2 VILLAGE SQ STE 210
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-1624
Mailing Address - Country:US
Mailing Address - Phone:614-844-5433
Mailing Address - Fax:614-987-8643
Practice Address - Street 1:6660 DOUBLETREE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-1128
Practice Address - Country:US
Practice Address - Phone:614-844-5433
Practice Address - Fax:614-987-8643
Is Sole Proprietor?:No
Enumeration Date:2022-09-16
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT-4396225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOT-4396Medicaid