Provider Demographics
NPI:1427829993
Name:MICHAEL, DUSTIN WILLIAM (CDCA)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:WILLIAM
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 MEADOW LN APT D
Mailing Address - Street 2:
Mailing Address - City:SOUTH POINT
Mailing Address - State:OH
Mailing Address - Zip Code:45680-8628
Mailing Address - Country:US
Mailing Address - Phone:740-764-6644
Mailing Address - Fax:
Practice Address - Street 1:57 TOWNSHIP HIGHWAY 1275
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:OH
Practice Address - Zip Code:45619
Practice Address - Country:US
Practice Address - Phone:740-451-0307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 175T00000X
OH187018101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist