Provider Demographics
NPI:1780033993
Name:PORT45 RECOVERY LLC
Entity Type:Organization
Organization Name:PORT45 RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-606-3141
Mailing Address - Street 1:921 EASTWIND DR STE 101
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-5302
Mailing Address - Country:US
Mailing Address - Phone:614-591-4710
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:740-529-7356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-08
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH101YA0400XMedicaid