Healthcare Provider Details

I. General information

NPI: 1578261814
Provider Name (Legal Business Name): TEVIS DORRELL ADULARESCENCE PEER SUPPORT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2023
Last Update Date: 08/18/2024
Certification Date: 08/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1228 WALNUT ST
CINCINNATI OH
45202-7135
US

IV. Provider business mailing address

1228 WALNUT ST APT 2
CINCINNATI OH
45202-7135
US

V. Phone/Fax

Practice location:
  • Phone: 513-913-6148
  • Fax:
Mailing address:
  • Phone: 513-913-6148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 7
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: