Healthcare Provider Details

I. General information

NPI: 1093772386
Provider Name (Legal Business Name): FIVE COUNTY ALCOHOL/DRUP PROGRAM IN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W MAIN ST
ALVORDTON OH
43501-9763
US

IV. Provider business mailing address

830 S CLINTON ST
DEFIANCE OH
43512-2758
US

V. Phone/Fax

Practice location:
  • Phone: 419-924-2029
  • Fax: 419-924-2061
Mailing address:
  • Phone: 419-782-9920
  • Fax: 419-784-2523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number0559
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number0559
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number0559
License Number StateOH

VIII. Authorized Official

Name: KENNETH BOND IV
Title or Position: EXECUTIVE DIRECTOR
Credential: LICDC
Phone: 419-782-9920