Provider Demographics
NPI:1245540087
Name:CARL WAYNE GRODY
Entity type:Organization
Organization Name:CARL WAYNE GRODY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:GRODY
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:614-889-6422
Mailing Address - Street 1:3982 POWELL RD
Mailing Address - Street 2:SUITE 271
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-7662
Mailing Address - Country:US
Mailing Address - Phone:614-889-6422
Mailing Address - Fax:614-453-8863
Practice Address - Street 1:5060 BRADENTON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3511
Practice Address - Country:US
Practice Address - Phone:614-889-6422
Practice Address - Fax:614-453-8863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 0900134104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty