Healthcare Provider Details

I. General information

NPI: 1376063339
Provider Name (Legal Business Name): DONALD JOSEPH GAUCK LICDC-CS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 EZZARD CHARLES DR
CINCINNATI OH
45214-2525
US

IV. Provider business mailing address

2622 MORROW PL
CINCINNATI OH
45204-2405
US

V. Phone/Fax

Practice location:
  • Phone: 513-381-6672
  • Fax: 513-381-6672
Mailing address:
  • Phone: 513-768-2942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number954218
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: