Provider Demographics
NPI:1053876623
Name:WOLFORD, BROCK (CDCA)
Entity type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:WOLFORD
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 1:30663 RED ROCK CT # 1
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-9672
Mailing Address - Country:US
Mailing Address - Phone:740-888-1377
Mailing Address - Fax:
Practice Address - Street 1:30663 RED ROCK CT # 1
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-9672
Practice Address - Country:US
Practice Address - Phone:740-888-1377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH169242101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0096642Medicaid