Provider Demographics
NPI:1821894627
Name:DAVIS, CONSTANCE MARLENE NICHOLE (CDCA)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:MARLENE NICHOLE
Last Name:DAVIS
Suffix:
Gender:
Credentials:CDCA
Other - Prefix:MRS
Other - First Name:CONSTANCE
Other - Middle Name:NICHOLE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CDCA
Mailing Address - Street 1:2221 MARGARET AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-2650
Mailing Address - Country:US
Mailing Address - Phone:614-633-9002
Mailing Address - Fax:
Practice Address - Street 1:525 METRO PL N STE 300
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-5320
Practice Address - Country:US
Practice Address - Phone:855-289-1722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-21
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA191619101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid