Provider Demographics
NPI:1023537446
Name:SUPINA, JOSEPH J IV (CDCA, PRS)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:J
Last Name:SUPINA
Suffix:IV
Gender:M
Credentials:CDCA, PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:GREEN SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:44836-9734
Mailing Address - Country:US
Mailing Address - Phone:844-534-3638
Mailing Address - Fax:
Practice Address - Street 1:430 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GREEN SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:44836-9734
Practice Address - Country:US
Practice Address - Phone:844-534-3638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.001751175T00000X
OHCDCA.190187101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH171M00000XMedicaid