Provider Demographics
NPI:1184130288
Name:TICEY, GARY WAYNE
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:WAYNE
Last Name:TICEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43620-1703
Mailing Address - Country:US
Mailing Address - Phone:419-841-7701
Mailing Address - Fax:
Practice Address - Street 1:6605 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43617-1000
Practice Address - Country:US
Practice Address - Phone:419-841-7701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-27
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH165227171M00000X
175T00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist