Basic Information
| Provider Information | |||||||||
| NPI: | 1699761809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRUE | ||||||||
| FirstName: | ROEHNELL | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | PCC, LICDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1067 GEORGIAN WAY | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437011502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404544456 | ||||||||
| FaxNumber: | 7404548183 | ||||||||
| Practice Location | |||||||||
| Address1: | 3620 COURT DR | ||||||||
| Address2: | |||||||||
| City: | ZANESVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437016456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404544456 | ||||||||
| FaxNumber: | 7404548183 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 12/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 001392 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | E-0003726 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP1600X | N/A | N | Behavioral Health & Social Service Providers | Counselor | Pastoral |
ID Information
| ID | Type | State | Issuer | Description | 472735000 | 01 | OH | MAGELLAN BEH. HEALTH PIN | OTHER | 000000300433 | 01 | OH | ANTHEM BS/BS PIN | OTHER |