Provider Demographics
NPI:1295377448
Name:CHESTER, COURTNEY (CDCA)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:CHESTER
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 MARKET AVE N
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1017
Mailing Address - Country:US
Mailing Address - Phone:330-493-4553
Mailing Address - Fax:330-493-3761
Practice Address - Street 1:624 MARKET AVE N
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702-1017
Practice Address - Country:US
Practice Address - Phone:330-493-4553
Practice Address - Fax:330-493-3761
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA172397101YA0400X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0396418Medicaid