Provider Demographics
NPI:1447987128
Name:ANTHONY, DUSTIN (CDCA)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:ANTHONY
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3735
Mailing Address - Country:US
Mailing Address - Phone:740-285-7617
Mailing Address - Fax:
Practice Address - Street 1:7175 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:MC DERMOTT
Practice Address - State:OH
Practice Address - Zip Code:45652-8899
Practice Address - Country:US
Practice Address - Phone:740-858-6683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-03
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YM0800X
OHCDCA.179889101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0001572Medicaid