Provider Demographics
NPI:1114657251
Name:WHEATON, JAMES TYLER (CDCA183858)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:TYLER
Last Name:WHEATON
Suffix:
Gender:M
Credentials:CDCA183858
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:OH
Mailing Address - Zip Code:45638-1403
Mailing Address - Country:US
Mailing Address - Phone:606-315-5094
Mailing Address - Fax:877-325-2816
Practice Address - Street 1:323 MARION PIKE STE 1
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638-2958
Practice Address - Country:US
Practice Address - Phone:740-237-4981
Practice Address - Fax:877-325-2816
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHCDCA.180399101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0491322Medicaid