MEDICARE: DARRICK RYAN FRALEY CDCA I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CDCA.165822	OH

General Provider Information

NPI Number	:	1104331073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARRICK RYAN FRALEY CDCA I

Provider Business Mailing Address
First Line	:	2396 CAREW AVE
Second Line	:
City	:	KETTERING
State	:	OH
Zip	:	45420-3427
Country	:	US
Telephone Number	:	937-312-7342
Fax Number	:

Provider Business Practice Location Address
First Line	:	1725 E 3RD ST
Second Line	:
City	:	DAYTON
State	:	OH
Zip	:	45403-1850
Country	:	US
Telephone Number	:	937-387-6395
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2017
Last Update Date	:	01/11/2019

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