Provider Demographics
NPI:1861436750
Name:REARDON, JAMES P (PHD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:P
Last Name:REARDON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 BRADENTON AVE
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-7515
Mailing Address - Country:US
Mailing Address - Phone:614-793-1980
Mailing Address - Fax:
Practice Address - Street 1:1660 NW PROFESSIONAL PLZ STE I
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-3831
Practice Address - Country:US
Practice Address - Phone:614-826-3566
Practice Address - Fax:614-826-3582
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2564103T00000X, 103TF0200X, 103TR0400X, 103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0355459Medicaid
OH0355459Medicaid