Provider Demographics
NPI:1346617545
Name:WAHREN, TULLEY J (PC)
Entity Type:Individual
Prefix:MR
First Name:TULLEY
Middle Name:J
Last Name:WAHREN
Suffix:
Gender:M
Credentials:PC
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 933421
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-426-2686
Mailing Address - Fax:937-426-6230
Practice Address - Street 1:1411 N FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2658
Practice Address - Country:US
Practice Address - Phone:937-426-2686
Practice Address - Fax:937-426-6230
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC1500056101YP2500X
OHE.1700409-SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0254708Medicaid