Healthcare Provider Details

I. General information

NPI: 1346016920
Provider Name (Legal Business Name): MR. RONALD ALLEN MABRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2023
Last Update Date: 12/01/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4483 US RTE 42
MASON OH
45040
US

IV. Provider business mailing address

4600 MONTGOMERY RD STE 400
CINCINNATI OH
45212-2600
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.185293
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: