Provider Demographics
NPI:1659312486
Name:CORLIS, LINDA (LISW)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:CORLIS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1971 W 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-1905
Mailing Address - Country:US
Mailing Address - Phone:614-488-6285
Mailing Address - Fax:
Practice Address - Street 1:1971 W 5TH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-1905
Practice Address - Country:US
Practice Address - Phone:614-488-6285
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-0001532104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicare ID - Type Unspecified