MEDICARE: GWENDOLYN HERTRICK

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	180743	OH

General Provider Information

NPI Number	:	1518605971
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN HERTRICK

Provider Business Mailing Address
First Line	:	1634 SYCAMORE LINE
Second Line	:
City	:	SANDUSKY
State	:	OH
Zip	:	44870-4132
Country	:	US
Telephone Number	:	419-626-9156
Fax Number	:

Provider Business Practice Location Address
First Line	:	5339 HARTLAND CENTER RD
Second Line	:
City	:	COLLINS
State	:	OH
Zip	:	44826-9738
Country	:	US
Telephone Number	:	724-417-0151
Fax Number	:

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

Provider Enumeration Date	:	05/25/2022
Last Update Date	:	05/25/2022

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Directions to “ GWENDOLYN HERTRICK ” Practice Location

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