Provider Demographics
NPI:1659568426
Name:SUPANCE, ALICIA C (LSW)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:C
Last Name:SUPANCE
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 POLARIS PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43240-2108
Mailing Address - Country:US
Mailing Address - Phone:614-430-9697
Mailing Address - Fax:
Practice Address - Street 1:2000 POLARIS PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43240-2108
Practice Address - Country:US
Practice Address - Phone:614-430-9697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.07008091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical