| Port45 Recovery Llc | |
|
1616 Grant St Portsmouth OH 45662-3663 | |
| (740) 529-7356 | |
| Not Available |
| Full Name | Port45 Recovery Llc |
|---|---|
| Speciality | Counselor |
| Location | 1616 Grant St, Portsmouth, Ohio |
| Authorized Official Name and Position | Sharon Staley (CEO) |
| Authorized Official Contact | 4196063141 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Port45 Recovery Llc 921 Eastwind Dr Ste 101 Westerville OH 43081-5302 Ph: (614) 591-4710 | Port45 Recovery Llc 1616 Grant St Portsmouth OH 45662-3663 Ph: (740) 529-7356 |
| NPI Number | 1780033993 |
|---|---|
| Provider Enumeration Date | 06/08/2016 |
| Last Update Date | 10/07/2019 |
| Medicare PECOS PAC ID | 0941537237 |
|---|---|
| Medicare Enrollment ID | O20190808003717 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1780033993 | NPI | - | NPPES |
| 101YA0400X | Medicaid | OH |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | (* (Not Available)) | Primary |
| Provider Name | Todd E Carter |
|---|---|
| Provider Type | Practitioner - Anesthesiology |
| Provider Identifiers | NPI Number: 1154400851 PECOS PAC ID: 4284703471 Enrollment ID: I20080514000143 |
| Provider Name | Erica Rochelle Shumway |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1699288357 PECOS PAC ID: 7911264262 Enrollment ID: I20171122000856 |
| Provider Name | Barbara A. Driscoll |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1700340999 PECOS PAC ID: 9931442217 Enrollment ID: I20190530001730 |
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