Basic Information
| Provider Information | |||||||||
| NPI: | 1053772301 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LONDRICO | ||||||||
| FirstName: | PHILIP | ||||||||
| MiddleName: | BRADLEY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 246 NORTHLAND DR STE 200A | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307259195 | ||||||||
| FaxNumber: | 3307259187 | ||||||||
| Practice Location | |||||||||
| Address1: | 246 NORTHLAND DR STE 200A | ||||||||
| Address2: | |||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307259195 | ||||||||
| FaxNumber: | 3307259187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2016 | ||||||||
| LastUpdateDate: | 10/30/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YA0400X | CDCA.163126 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 0098487 | 05 | OH | MEDICAID |