Healthcare Provider Details

I. General information

NPI: 1811757628
Provider Name (Legal Business Name): ANNIE NICOLE NORTHROP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 06/20/2025
Certification Date: 06/20/2025
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: 937-291-2300
  • Fax: 937-291-2303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.004909
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: