Healthcare Provider Details

I. General information

NPI: 1164087607
Provider Name (Legal Business Name): SHERRY ANN PRINCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 05/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1354 JACKSON PIKE
GALLIPOLIS OH
45631-2601
US

IV. Provider business mailing address

1582 TOWNSHIP ROAD 256
KITTS HILL OH
45645-8883
US

V. Phone/Fax

Practice location:
  • Phone: 740-441-9800
  • Fax: 740-441-9400
Mailing address:
  • Phone: 740-547-7931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number169335
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: