Provider Demographics
NPI:1700693744
Name:WELLER, TINA (LCDCIII-ICADC)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:WELLER
Suffix:
Gender:F
Credentials:LCDCIII-ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 HARRISBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43223-2525
Mailing Address - Country:US
Mailing Address - Phone:614-276-4840
Mailing Address - Fax:614-276-4746
Practice Address - Street 1:1034 HARRISBURG PIKE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43223-2525
Practice Address - Country:US
Practice Address - Phone:614-276-4840
Practice Address - Fax:614-276-4746
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.001404101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)