Provider Demographics
NPI:1821502063
Name:STALLWORTH, ERNEST (CDCA)
Entity Type:Individual
Prefix:MR
First Name:ERNEST
Middle Name:
Last Name:STALLWORTH
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:PO BOX 8189
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-0189
Mailing Address - Country:US
Mailing Address - Phone:330-867-5400
Mailing Address - Fax:330-869-8263
Practice Address - Street 1:1735 S HAWKINS AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-3902
Practice Address - Country:US
Practice Address - Phone:330-867-5400
Practice Address - Fax:330-869-8263
Is Sole Proprietor?:No
Enumeration Date:2017-11-27
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH164469101YA0400X
171M00000X
OH168922101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator