Basic Information
| Provider Information | |||||||||
| NPI: | 1619445699 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WHEELER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11 W MONUMENT AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454021293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373194448 | ||||||||
| FaxNumber: | 9376304391 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 W MONUMENT AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454021293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373194448 | ||||||||
| FaxNumber: | 9376304391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2018 | ||||||||
| LastUpdateDate: | 09/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | C.1901918 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 0330742 | 05 | OH | MEDICAID |