Healthcare Provider Details

I. General information

NPI: 1649107707
Provider Name (Legal Business Name): MELONEY WILSON CDCAPRE.195839
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6770 AVERY MUIRFIELD DR
DUBLIN OH
43017-1241
US

IV. Provider business mailing address

116 HARVARD AVE
MANSFIELD OH
44906-2819
US

V. Phone/Fax

Practice location:
  • Phone: 888-251-2365
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCAPRE.195839
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: