Healthcare Provider Details

I. General information

NPI: 1003318734
Provider Name (Legal Business Name): SEAN HOWARD GROSSARTH PSA, CDCA-P, RA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S COLUMBUS ST
LANCASTER OH
43130-4315
US

IV. Provider business mailing address

201 S COLUMBUS ST
LANCASTER OH
43130-4315
US

V. Phone/Fax

Practice location:
  • Phone: 740-687-4500
  • Fax: 740-687-4595
Mailing address:
  • Phone: 740-687-4500
  • Fax: 740-687-4595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberRA.161611
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.166229
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number00435
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: