Provider Demographics
NPI:1821877697
Name:GORE, HEATHER (CDCA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:GORE
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17825 CRADLER TURNER RD
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-9336
Mailing Address - Country:US
Mailing Address - Phone:937-707-4662
Mailing Address - Fax:833-392-1202
Practice Address - Street 1:4995 BRADENTON AVE STE 110
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3551
Practice Address - Country:US
Practice Address - Phone:614-515-2500
Practice Address - Fax:614-573-0530
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.171106101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty