Provider Demographics
NPI:1073229001
Name:BACCUS, GERALD LEE
Entity Type:Individual
Prefix:
First Name:GERALD
Middle Name:LEE
Last Name:BACCUS
Suffix:
Gender:M
Credentials:
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 10232 SOUTH LUDLOW ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402
Mailing Address - Country:US
Mailing Address - Phone:937-559-2255
Mailing Address - Fax:
Practice Address - Street 1:2400 W STROOP RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45439-2041
Practice Address - Country:US
Practice Address - Phone:614-634-0195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH183243101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)