Healthcare Provider Details

I. General information

NPI: 1417460221
Provider Name (Legal Business Name): ROBERT TODD CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 11/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48 PRIVATE DRIVE 339
SOUTH POINT OH
45680-8919
US

IV. Provider business mailing address

48 PRIVATE DRIVE 339
SOUTH POINT OH
45680-8919
US

V. Phone/Fax

Practice location:
  • Phone: 740-451-1455
  • Fax:
Mailing address:
  • Phone: 740-451-1455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.164625
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: