Provider Demographics
NPI:1790272029
Name:PHELPS, COURTNEY (CDCA 173558)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:PHELPS
Suffix:
Gender:F
Credentials:CDCA 173558
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 MARION PIKE STE 3
Mailing Address - Street 2:
Mailing Address - City:COAL GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2958
Mailing Address - Country:US
Mailing Address - Phone:740-646-6640
Mailing Address - Fax:
Practice Address - Street 1:323 MARION PIKE STE 3
Practice Address - Street 2:
Practice Address - City:COAL GROVE
Practice Address - State:OH
Practice Address - Zip Code:45638-2958
Practice Address - Country:US
Practice Address - Phone:740-646-6640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-23
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.173558101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0292316Medicaid