Healthcare Provider Details

I. General information

NPI: 1760985790
Provider Name (Legal Business Name): JOHN WEBSTER NEE CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 03/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1134 JACKSON PIKE
GALLIPOLIS OH
45631-2600
US

IV. Provider business mailing address

1017 BELMONT ST
CHARLESTON WV
25314-1738
US

V. Phone/Fax

Practice location:
  • Phone: 740-446-6020
  • Fax:
Mailing address:
  • Phone: 602-736-6973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number165254
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: