Provider Demographics
NPI:1154734697
Name:IRWIN, ROBERT THORNTON (LICDC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:THORNTON
Last Name:IRWIN
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 1:68518 BANNOCK RD
Mailing Address - Street 2:P.O. 540
Mailing Address - City:SAINT CLAIRSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43950-9736
Mailing Address - Country:US
Mailing Address - Phone:740-695-5169
Mailing Address - Fax:
Practice Address - Street 1:68518 BANNOCK RD
Practice Address - Street 2:P.O. 540
Practice Address - City:SAINT CLAIRSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43950-9736
Practice Address - Country:US
Practice Address - Phone:740-695-5169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121104101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)