MEDICARE: DUSTIN KEITH KERN LICDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	LICDC.163025	OH

General Provider Information

NPI Number	:	1962161141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTIN KEITH KERN LICDC

Provider Business Mailing Address
First Line	:	625 CLEVELAND AVE NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44702-1805
Country	:	US
Telephone Number	:	330-455-0374
Fax Number	:	330-453-6716

Provider Business Practice Location Address
First Line	:	1680 NAVE RD SE
Second Line	:
City	:	MASSILLON
State	:	OH
Zip	:	44646-9604
Country	:	US
Telephone Number	:	330-830-8740
Fax Number	:	330-830-0912

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2021
Last Update Date	:	06/15/2026

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