Provider Demographics
NPI:1114657251
Name:WHEATON, JAMES TYLER (CDCA183858)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:TYLER
Last Name:WHEATON
Suffix:
Gender:M
Credentials:CDCA183858
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 COURT ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3932
Mailing Address - Country:US
Mailing Address - Phone:740-354-6685
Mailing Address - Fax:740-354-6685
Practice Address - Street 1:411 COURT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3932
Practice Address - Country:US
Practice Address - Phone:740-354-6685
Practice Address - Fax:740-876-4005
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHCDCA.180399101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0491322Medicaid