Provider Demographics
NPI:1598325144
Name:HERNER, CHAD MICHAEL (CDCA)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:MICHAEL
Last Name:HERNER
Suffix:
Gender:M
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:PO BOX 502
Mailing Address - Street 2:
Mailing Address - City:BLOOMVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44818-0502
Mailing Address - Country:US
Mailing Address - Phone:419-681-2845
Mailing Address - Fax:
Practice Address - Street 1:117 BLOSSOM CENTRE BLVD
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:OH
Practice Address - Zip Code:44890-9317
Practice Address - Country:US
Practice Address - Phone:567-560-3586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHCDCA.171312101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator