Provider Demographics
NPI:1639631617
Name:GOGOLIN, THOMAS RYAN (CDCA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:RYAN
Last Name:GOGOLIN
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 1:1649 BRICE RD
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-2758
Mailing Address - Country:US
Mailing Address - Phone:614-300-5878
Mailing Address - Fax:
Practice Address - Street 1:1649 BRICE RD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-2758
Practice Address - Country:US
Practice Address - Phone:614-300-5878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCII.161660101YA0400X
OHC.2204415101YM0800X
OHLICDC.162176101YA0400X
101YA0400X
OHCDCA.170438101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health