Healthcare Provider Details

I. General information

NPI: 1841562949
Provider Name (Legal Business Name): CEDRICK D GOODEN LCDCIII, OCPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CLEVELAND AVE NW
CANTON OH
44702-1836
US

IV. Provider business mailing address

625 CLEVELAND AVE NW
CANTON OH
44702-1805
US

V. Phone/Fax

Practice location:
  • Phone: 330-455-0374
  • Fax: 330-453-6716
Mailing address:
  • Phone: 330-455-0374
  • Fax: 330-453-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII161791
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberOCPS4486
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: