=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518605971
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GWENDOLYN HERTRICK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2022
-----------------------------------------------------
Last Update Date | 05/25/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5339 HARTLAND CENTER RD
-----------------------------------------------------
City | COLLINS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44826-9738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-417-0151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1634 SYCAMORE LINE
-----------------------------------------------------
City | SANDUSKY
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44870-4132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-626-9156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 180743
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------