Provider Demographics
NPI:1912401373
Name:GOLLA, CANDIDA L
Entity Type:Individual
Prefix:
First Name:CANDIDA
Middle Name:L
Last Name:GOLLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CANDIDA
Other - Middle Name:L
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 CHILDRENS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 CHILDRENS DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2639
Practice Address - Country:US
Practice Address - Phone:614-722-4888
Practice Address - Fax:614-722-9376
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.2102513101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1473276Medicaid