Provider Demographics
NPI:1609388321
Name:MCPHETERS, ADAM RAY (LICDC)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:RAY
Last Name:MCPHETERS
Suffix:
Gender:M
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4304 OLD SCIOTO TRL
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-6672
Mailing Address - Country:US
Mailing Address - Phone:740-351-9298
Mailing Address - Fax:740-529-0553
Practice Address - Street 1:4304 OLD SCIOTO TRL
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-6672
Practice Address - Country:US
Practice Address - Phone:740-354-6685
Practice Address - Fax:740-529-0553
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH091043101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0272138Medicaid