Healthcare Provider Details

I. General information

NPI: 1760313647
Provider Name (Legal Business Name): JUSTIN ADDY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E STATE ST STE D
ATHENS OH
45701-1870
US

IV. Provider business mailing address

50024 TOWNSHIP ROAD 430
FRESNO OH
43824-9752
US

V. Phone/Fax

Practice location:
  • Phone: 866-534-2639
  • Fax: 800-480-7578
Mailing address:
  • Phone: 740-610-6284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: