Provider Demographics
NPI:1417414723
Name:SEYMOUR, DAVID A
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:SEYMOUR
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:PO BOX 724
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-0724
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10050 BASSETT RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-3626
Practice Address - Country:US
Practice Address - Phone:740-593-3890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-22
Last Update Date:2019-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH169750101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2314525Medicaid
OH2864002Medicaid