Healthcare Provider Details

I. General information

NPI: 1437512761
Provider Name (Legal Business Name): JAMES GONNELLA LICDC, GAMB, LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 04/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6539 MOSES RD
WEST ALEXANDRIA OH
45381-8582
US

IV. Provider business mailing address

6539 MOSES RD
WEST ALEXANDRIA OH
45381-8582
US

V. Phone/Fax

Practice location:
  • Phone: 937-461-5223
  • Fax: 937-461-7010
Mailing address:
  • Phone: 937-461-5223
  • Fax: 937-461-7010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberS.1201491
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: