Healthcare Provider Details

I. General information

NPI: 1497533418
Provider Name (Legal Business Name): CORY CHRISTIE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 05/11/2024
Certification Date: 05/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 NORTH RD SE
WARREN OH
44484-2907
US

IV. Provider business mailing address

3744 MAHONING AVE NW
WARREN OH
44483-1920
US

V. Phone/Fax

Practice location:
  • Phone: 330-539-3200
  • Fax:
Mailing address:
  • Phone: 234-283-3483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.004460
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: