Provider Demographics
NPI:1770047409
Name:MCDUFFIE, HOMER JR (LCDCLL)
Entity Type:Individual
Prefix:
First Name:HOMER
Middle Name:
Last Name:MCDUFFIE
Suffix:JR
Gender:M
Credentials:LCDCLL
Other - Prefix:
Other - First Name:HOMER
Other - Middle Name:
Other - Last Name:MCDUFFIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COUNSELOR
Mailing Address - Street 1:547 E 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-2603
Mailing Address - Country:US
Mailing Address - Phone:614-224-4506
Mailing Address - Fax:614-291-0118
Practice Address - Street 1:547 E 11TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43211-2603
Practice Address - Country:US
Practice Address - Phone:614-224-4506
Practice Address - Fax:614-291-0118
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCLL161678101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH17700474009Medicaid