Basic Information
| Provider Information | |||||||||
| NPI: | 1457983488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNICKERBOCKER | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | |||||||||
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| Credential: | COUNSELOR TRNE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 S CADILLAC DR | ||||||||
| Address2: | |||||||||
| City: | BOARDMAN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 445123324 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15898 SAINT CLAIR AVE # 1 | ||||||||
| Address2: | |||||||||
| City: | EAST LIVERPOOL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 439209122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3309530243 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2020 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | C.1901855-TRNE | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YA0400X | C.2002851 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.