Provider Demographics
NPI:1689447930
Name:CAPTAIN, RALPH MICHAEL
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:MICHAEL
Last Name:CAPTAIN
Suffix:
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:PO BOX 212
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-0212
Mailing Address - Country:US
Mailing Address - Phone:937-708-8348
Mailing Address - Fax:
Practice Address - Street 1:1 ELIZABETH PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3445
Practice Address - Country:US
Practice Address - Phone:937-520-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-30
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.186820101YA0400X
OHAPS.003572175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPS.003572OtherSTATE OF OHIO MENTAL HEALTH AND ADDICTION SERVICES