Healthcare Provider Details

I. General information

NPI: 1801410550
Provider Name (Legal Business Name): TEQUILA MARIE ESTEP CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 SWAUGER VALLEY RD
PORTSMOUTH OH
45662-9097
US

IV. Provider business mailing address

303 GERVAIS RD
FRANKLIN FURNACE OH
45629-8742
US

V. Phone/Fax

Practice location:
  • Phone: 740-716-9270
  • Fax:
Mailing address:
  • Phone: 740-259-7000
  • Fax: 740-259-7003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number173593
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: