Basic Information
| Provider Information | |||||||||
| NPI: | 1598325144 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERNER | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | CDCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 502 | ||||||||
| Address2: | |||||||||
| City: | BLOOMVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448180502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196812845 | ||||||||
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| Practice Location | |||||||||
| Address1: | 117 BLOSSOM CENTRE BLVD | ||||||||
| Address2: | |||||||||
| City: | WILLARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448909317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5675603586 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2019 | ||||||||
| LastUpdateDate: | 08/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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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.171312 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.