Provider Demographics
NPI:1962014647
Name:UPSHAW, ANJANETTE (MED)
Entity Type:Individual
Prefix:
First Name:ANJANETTE
Middle Name:
Last Name:UPSHAW
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 HOLLYBRIER DR APT 119
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-8473
Mailing Address - Country:US
Mailing Address - Phone:216-548-4466
Mailing Address - Fax:
Practice Address - Street 1:1400 HOLLYBRIER DR APT 119
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-8473
Practice Address - Country:US
Practice Address - Phone:216-548-4466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-23
Last Update Date:2020-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst