Provider Demographics
NPI:1811486699
Name:CARTER, KATHY L (CDCA)
Entity type:Individual
Prefix:MS
First Name:KATHY
Middle Name:L
Last Name:CARTER
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 BRYDEN RD., SUITE 122
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215
Mailing Address - Country:US
Mailing Address - Phone:614-432-3356
Mailing Address - Fax:614-396-9331
Practice Address - Street 1:700 BRYDEN RD., SUITE 122
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215
Practice Address - Country:US
Practice Address - Phone:614-681-0012
Practice Address - Fax:614-412-6944
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.178722171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0283199Medicaid