=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821877697
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HEATHER GORE CDCA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2023
-----------------------------------------------------
Last Update Date | 11/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4995 BRADENTON AVE STE 110
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43017-3551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-515-2500
-----------------------------------------------------
Fax | 614-573-0530
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17825 CRADLER TURNER RD
-----------------------------------------------------
City | MARYSVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43040-9336
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-707-4662
-----------------------------------------------------
Fax | 833-392-1202
-----------------------------------------------------
=====================================================
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 | CDCA.171106
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------