Provider Demographics
NPI:1114437217
Name:STORTS, DEDRA MARIE (AAS, CDCA, QMHS)
Entity Type:Individual
Prefix:
First Name:DEDRA
Middle Name:MARIE
Last Name:STORTS
Suffix:
Gender:F
Credentials:AAS, CDCA, QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 BELL ST
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1720
Mailing Address - Country:US
Mailing Address - Phone:740-454-9766
Mailing Address - Fax:740-588-6452
Practice Address - Street 1:1375 COMMERCE DR
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-9511
Practice Address - Country:US
Practice Address - Phone:740-342-5154
Practice Address - Fax:740-342-6704
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.163623101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0280874Medicaid