Healthcare Provider Details

I. General information

NPI: 1851630875
Provider Name (Legal Business Name): DEAN R OWEN LICDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2013
Last Update Date: 09/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8402 BLACKJACK ROAD EXT
MOUNT VERNON OH
43050-9193
US

IV. Provider business mailing address

PO BOX 4670
NEWARK OH
43058-4670
US

V. Phone/Fax

Practice location:
  • Phone: 740-522-8477
  • Fax: 740-788-3424
Mailing address:
  • Phone: 740-522-8477
  • Fax: 740-788-3424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICDC 933671-CS
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0013531
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: