Healthcare Provider Details

I. General information

NPI: 1750067146
Provider Name (Legal Business Name): ANGELA E MAIRS CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 3RD AVE
CHESAPEAKE OH
45619-1036
US

IV. Provider business mailing address

2604 4TH AVE
HUNTINGTON WV
25702-1306
US

V. Phone/Fax

Practice location:
  • Phone: 740-451-1455
  • 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.186864
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: