Provider Demographics
NPI:1669954103
Name:LUNSFORD, DOUGLAS
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:LUNSFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5925 CLEVELAND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-2209
Mailing Address - Country:US
Mailing Address - Phone:614-776-4646
Mailing Address - Fax:614-398-0039
Practice Address - Street 1:5925 CLEVELAND AVE STE B
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-2209
Practice Address - Country:US
Practice Address - Phone:614-776-4646
Practice Address - Fax:614-398-0039
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHCDCA.169549101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty