Healthcare Provider Details

I. General information

NPI: 1760218200
Provider Name (Legal Business Name): CHAD TISH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5563 FAR HILLS AVE
DAYTON OH
45429-2225
US

IV. Provider business mailing address

5563 FAR HILLS AVE
DAYTON OH
45429-2225
US

V. Phone/Fax

Practice location:
  • Phone: 937-291-2300
  • Fax: 937-291-2303
Mailing address:
  • Phone: 740-485-2326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.189716
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number193842
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: