Provider Demographics
NPI:1396276432
Name:LARUE PSYCHIATRIC SERVICES LLC
Entity type:Organization
Organization Name:LARUE PSYCHIATRIC SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CERTFIED NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KHALILAH
Authorized Official - Middle Name:KRYSTAL
Authorized Official - Last Name:LARUE
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:614-668-2149
Mailing Address - Street 1:4449 EASTON WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-7005
Mailing Address - Country:US
Mailing Address - Phone:614-208-4973
Mailing Address - Fax:888-858-4293
Practice Address - Street 1:4449 EASTON WAY STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-7005
Practice Address - Country:US
Practice Address - Phone:614-208-4973
Practice Address - Fax:888-858-4293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10483251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0076744Medicaid
GA003260122BMedicaid