Healthcare Provider Details

I. General information

NPI: 1073229001
Provider Name (Legal Business Name): GERALD LEE BACCUS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2023
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 W STROOP RD
DAYTON OH
45439-2041
US

IV. Provider business mailing address

PO BOX 10232
DAYTON OH
45402-7232
US

V. Phone/Fax

Practice location:
  • Phone: 614-634-0195
  • Fax:
Mailing address:
  • Phone: 937-559-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number183243
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: