Healthcare Provider Details

I. General information

NPI: 1578249637
Provider Name (Legal Business Name): AUSTIN WESCOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2023
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 N MAIN ST
DAYTON OH
45405-1624
US

IV. Provider business mailing address

337 HILL ST
XENIA OH
45385-5654
US

V. Phone/Fax

Practice location:
  • Phone: 937-203-2017
  • Fax:
Mailing address:
  • Phone: 917-919-3276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.184718
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: