Provider Demographics
NPI:1679793681
Name:ALDEN, KATHY ILENE
Entity Type:Individual
Prefix:MS
First Name:KATHY
Middle Name:ILENE
Last Name:ALDEN
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 1:1865 UPPER CHELSEA RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-1939
Mailing Address - Country:US
Mailing Address - Phone:614-477-5720
Mailing Address - Fax:
Practice Address - Street 1:1865 UPPER CHELSEA RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-1939
Practice Address - Country:US
Practice Address - Phone:614-477-5720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2624664172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2624664Medicaid
OH2530452OtherODMRDD CONTRACT NUMBER