Healthcare Provider Details

I. General information

NPI: 1346804382
Provider Name (Legal Business Name): MICHAEL D MCCOY CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 GRANVILLE PIKE
LANCASTER OH
43130-1041
US

IV. Provider business mailing address

615 ELSINORE PL STE 200
CINCINNATI OH
45202-1457
US

V. Phone/Fax

Practice location:
  • Phone: 833-510-4357
  • Fax: 866-460-2997
Mailing address:
  • Phone: 833-510-4357
  • Fax: 866-460-2997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.170333
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: