Provider Demographics
NPI:1386400646
Name:DEGENNARO, ELIZABETH GWEN (CDCA)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:GWEN
Last Name:DEGENNARO
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:GWEN
Other - Last Name:GLEICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1323 E 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-2554
Mailing Address - Country:US
Mailing Address - Phone:614-972-5160
Mailing Address - Fax:
Practice Address - Street 1:1323 E 18TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43211-2554
Practice Address - Country:US
Practice Address - Phone:614-972-5160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.187392101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)