Healthcare Provider Details

I. General information

NPI: 1114576485
Provider Name (Legal Business Name): COURTNEY DAWN WHITBREAD LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 C CT
ASHTABULA OH
44004-4577
US

IV. Provider business mailing address

2801 C CT
ASHTABULA OH
44004-4577
US

V. Phone/Fax

Practice location:
  • Phone: 440-998-4210
  • Fax:
Mailing address:
  • Phone: 440-998-4210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2607981
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.162319
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: