Provider Demographics
NPI:1922356203
Name:BRISCOE, FAITH M
Entity Type:Individual
Prefix:
First Name:FAITH
Middle Name:M
Last Name:BRISCOE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FAITH
Other - Middle Name:M
Other - Last Name:BLOUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 715194
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-5194
Mailing Address - Country:US
Mailing Address - Phone:614-355-8004
Mailing Address - Fax:614-355-0509
Practice Address - Street 1:399 E MAIN ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-5384
Practice Address - Country:US
Practice Address - Phone:614-355-8550
Practice Address - Fax:614-355-8593
Is Sole Proprietor?:No
Enumeration Date:2012-08-17
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.11014001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid