Provider Demographics
NPI:1144714478
Name:CLOSS, CHEYANNE NICOLE (CDCA)
Entity type:Individual
Prefix:
First Name:CHEYANNE
Middle Name:NICOLE
Last Name:CLOSS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-1180
Mailing Address - Country:US
Mailing Address - Phone:740-577-6671
Mailing Address - Fax:
Practice Address - Street 1:11821 STATE ROUTE 160
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:OH
Practice Address - Zip Code:45686-9009
Practice Address - Country:US
Practice Address - Phone:740-245-3051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH166820101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0145313Medicaid