Healthcare Provider Details

I. General information

NPI: 1205440997
Provider Name (Legal Business Name): ROBERT W HERRICK CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2020
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 COUNTY ROAD 31
CHESAPEAKE OH
45619-8073
US

IV. Provider business mailing address

1560 COUNTY ROAD 31
CHESAPEAKE OH
45619-8073
US

V. Phone/Fax

Practice location:
  • Phone: 740-451-0483
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.174407
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: