Provider Demographics
NPI:1184022113
Name:GRESOCK, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:GRESOCK
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 1:897 E IRON AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2030
Mailing Address - Country:US
Mailing Address - Phone:330-343-5555
Mailing Address - Fax:330-343-1601
Practice Address - Street 1:897 E IRON AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2030
Practice Address - Country:US
Practice Address - Phone:330-343-5555
Practice Address - Fax:330-343-1601
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDC.141244-3101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)