Healthcare Provider Details

I. General information

NPI: 1326648411
Provider Name (Legal Business Name): GREGORY CARTER SMITH CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 JACKSON PIKE
GALLIPOLIS OH
45631-1398
US

IV. Provider business mailing address

1560 COUNTY ROAD 31
CHESAPEAKE OH
45619-8073
US

V. Phone/Fax

Practice location:
  • Phone: 740-446-6471
  • Fax: 740-441-2928
Mailing address:
  • Phone: 740-451-0483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.174856
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: