Healthcare Provider Details

I. General information

NPI: 1841506193
Provider Name (Legal Business Name): DESIREE MICHELLE GARRISON LCDC-2, SWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

953 S SOUTH ST
WILMINGTON OH
45177-2921
US

IV. Provider business mailing address

975 KINGSVIEW DR SUITE 400
LEBANON OH
45036-9562
US

V. Phone/Fax

Practice location:
  • Phone: 937-383-4441
  • Fax: 937-383-2348
Mailing address:
  • Phone: 513-228-7854
  • Fax: 513-228-7848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDC.131024-2
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberW-0900049
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: