Provider Demographics
NPI:1316461262
Name:COOLEY, DUSTIN
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:COOLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 WARDS CORNER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-6966
Mailing Address - Country:US
Mailing Address - Phone:513-576-7700
Mailing Address - Fax:513-576-1020
Practice Address - Street 1:631 EAST ST. STREET
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:OH
Practice Address - Zip Code:45121-1437
Practice Address - Country:US
Practice Address - Phone:937-378-6387
Practice Address - Fax:937-378-4253
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1600773104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0273142Medicaid