Provider Demographics
NPI:1053845701
Name:WELCH, ROBERT JR (LICDC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WELCH
Suffix:JR
Gender:M
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2513
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45401-2513
Mailing Address - Country:US
Mailing Address - Phone:937-572-2168
Mailing Address - Fax:
Practice Address - Street 1:200 ROCKRIDGE RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2794
Practice Address - Country:US
Practice Address - Phone:937-365-2110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC 001106101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)