Individual
GILLYAN BACCUS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
4124 LINDEN AVE, DAYTON, OH 45432-3018
(937) 522-0961
Mailing address
4309 PIMLICO PL, HUBER HEIGHTS, OH 45424-3883
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
Primary
CDCA.169595
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CDCA.169595
OHIO CHEMICAL DEPENDENCY BOARD
OH
Enumeration date
09/03/2019
Last updated
09/03/2019
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