Provider Demographics
NPI:1700240157
Name:DURHAM, TRICIA (ATS, CDCA)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:DURHAM
Suffix:
Gender:F
Credentials:ATS, CDCA
Other - Prefix:
Other - First Name:TRICIA
Other - Middle Name:
Other - Last Name:DURHAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ATS, CDCA
Mailing Address - Street 1:2345 FREDA DR
Mailing Address - Street 2:
Mailing Address - City:BUCYRUS
Mailing Address - State:OH
Mailing Address - Zip Code:44820-2007
Mailing Address - Country:US
Mailing Address - Phone:419-522-5015
Mailing Address - Fax:419-522-5017
Practice Address - Street 1:13 PARK AVE W
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44902-1714
Practice Address - Country:US
Practice Address - Phone:419-562-2501
Practice Address - Fax:419-522-5017
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH141569101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)