Provider Demographics
NPI:1679198840
Name:STILTNER, CHAD (CDCA181056)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:STILTNER
Suffix:
Gender:M
Credentials:CDCA181056
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3932
Mailing Address - Country:US
Mailing Address - Phone:740-354-6685
Mailing Address - Fax:
Practice Address - Street 1:1616 GRANT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3663
Practice Address - Country:US
Practice Address - Phone:740-901-0416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.176495101YA0400X
101YM0800X
OHCDCA.181056101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0406725Medicaid