Provider Demographics
NPI: | 1851678650 |
---|---|
Name: | WEILER, GARY R (PCC, LICDC) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | GARY |
Middle Name: | R |
Last Name: | WEILER |
Suffix: | |
Gender: | M |
Credentials: | PCC, LICDC |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 8479 S. MASON MONTGOMERY ROAD |
Mailing Address - Street 2: | |
Mailing Address - City: | MASON |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45040-4023 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 513-253-5638 |
Mailing Address - Fax: | 513-725-1141 |
Practice Address - Street 1: | 8479 S. MASON MONTGOMERY ROAD |
Practice Address - Street 2: | |
Practice Address - City: | MASON |
Practice Address - State: | OH |
Practice Address - Zip Code: | 45040-4023 |
Practice Address - Country: | US |
Practice Address - Phone: | 513-253-5638 |
Practice Address - Fax: | 513-725-1141 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2011-11-08 |
Last Update Date: | 2020-01-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | E.1600057 | 101YP2500X |
OH | 954219 | 101YA0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional |
No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 0178432 | Medicaid |