Provider Demographics
NPI:1851678650
Name:WEILER, GARY R (PCC, LICDC)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:R
Last Name:WEILER
Suffix:
Gender:M
Credentials:PCC, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8479 S. MASON MONTGOMERY ROAD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-4023
Mailing Address - Country:US
Mailing Address - Phone:513-253-5638
Mailing Address - Fax:513-725-1141
Practice Address - Street 1:8479 S. MASON MONTGOMERY ROAD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-4023
Practice Address - Country:US
Practice Address - Phone:513-253-5638
Practice Address - Fax:513-725-1141
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1600057101YP2500X
OH954219101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0178432Medicaid