Provider Demographics
NPI:1053967240
Name:DEARMOND, WILLARD DAN JR
Entity type:Individual
Prefix:
First Name:WILLARD
Middle Name:DAN
Last Name:DEARMOND
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2624 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45505-2620
Mailing Address - Country:US
Mailing Address - Phone:937-328-5300
Mailing Address - Fax:937-322-4900
Practice Address - Street 1:2624 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45505-2620
Practice Address - Country:US
Practice Address - Phone:937-328-5300
Practice Address - Fax:937-322-4900
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-13
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLICDC.162479101YA0400X
OHS.2005412104100000X, 171M00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator