Healthcare Provider Details

I. General information

NPI: 1942750070
Provider Name (Legal Business Name): KURT DUPONT CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8440 MARKET ST STE 200
BOARDMAN OH
44512-6702
US

IV. Provider business mailing address

8440 MARKET ST STE 200
BOARDMAN OH
44512-6702
US

V. Phone/Fax

Practice location:
  • Phone: 330-286-0050
  • Fax: 330-286-0055
Mailing address:
  • Phone: 330-286-0050
  • Fax: 330-286-0055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number140851
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: