Healthcare Provider Details

I. General information

NPI: 1396494761
Provider Name (Legal Business Name): GARY BADDELEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23611 CHAGRIN BLVD STE 103
BEACHWOOD OH
44122-5540
US

IV. Provider business mailing address

23611 CHAGRIN BLVD STE 103
BEACHWOOD OH
44122-5540
US

V. Phone/Fax

Practice location:
  • Phone: 844-316-7599
  • Fax:
Mailing address:
  • Phone: 844-316-7599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCAPRE.195775
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberPRS.005700
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: