Basic Information
| Provider Information | |||||||||
| NPI: | 1528505153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRZELAK | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 COOK RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450369600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132287800 | ||||||||
| FaxNumber: | 5137252231 | ||||||||
| Practice Location | |||||||||
| Address1: | 953 S SOUTH ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451772921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373834441 | ||||||||
| FaxNumber: | 9373832916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2017 | ||||||||
| LastUpdateDate: | 01/20/2017 | ||||||||
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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 | 101YA0400X | CDCA-162499 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.