MEDICARE: SEAN PHILLIPS RECOVERY CENTER LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407553894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEAN PHILLIPS RECOVERY CENTER LLC

Provider Business Mailing Address
First Line	:	604 OFFICE PKWY
Second Line	:
City	:	WESTERVILLE
State	:	OH
Zip	:	43082-7938
Country	:	US
Telephone Number	:	614-430-9590
Fax Number	:

Provider Business Practice Location Address
First Line	:	695 S MOUNT VERNON AVE
Second Line	:
City	:	LOUDONVILLE
State	:	OH
Zip	:	44842-1414
Country	:	US
Telephone Number	:	614-832-7647
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	CHAUNCEY D WALLACE
Credential	:
Telephone Number	:	614-832-7647

Provider Enumeration Date	:	02/15/2023
Last Update Date	:	02/15/2023

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