Provider Demographics
NPI:1194589408
Name:DIRTY SOUTH THERAPEUTICS LLC
Entity type:Organization
Organization Name:DIRTY SOUTH THERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:MATHUEWS
Authorized Official - Suffix:JR
Authorized Official - Credentials:LISW-S
Authorized Official - Phone:740-701-2890
Mailing Address - Street 1:77 E WATER ST STE 217
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-2586
Mailing Address - Country:US
Mailing Address - Phone:740-701-2890
Mailing Address - Fax:
Practice Address - Street 1:77 E WATER ST STE 217
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-2586
Practice Address - Country:US
Practice Address - Phone:740-701-2890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty