Provider Demographics
NPI:1386118156
Name:HARRELL, STEPHEN MALCOLM
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MALCOLM
Last Name:HARRELL
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 1:328 BUCKINGHAM ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-2177
Mailing Address - Country:US
Mailing Address - Phone:614-824-6885
Mailing Address - Fax:614-824-6894
Practice Address - Street 1:328 BUCKINGHAM ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-2177
Practice Address - Country:US
Practice Address - Phone:614-824-6885
Practice Address - Fax:614-824-6894
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH171M00000XMedicaid