Healthcare Provider Details

I. General information

NPI: 1912514019
Provider Name (Legal Business Name): DYLAN SULLIVAN COUNSELOR TRNE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 DIXIE HWY
HAMILTON OH
45015-1653
US

IV. Provider business mailing address

3103 DIXIE HWY
HAMILTON OH
45015-1653
US

V. Phone/Fax

Practice location:
  • Phone: 513-892-4673
  • Fax: 513-737-1107
Mailing address:
  • Phone: 513-892-4673
  • Fax: 513-737-1107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC2203820-TRNE
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number0002025
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC.2203820-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: