Provider Demographics
NPI:1184249310
Name:VONTRELLE, SUSANNA FAITH (ADDICTIONS COUNSELOR)
Entity type:Individual
Prefix:MS
First Name:SUSANNA
Middle Name:FAITH
Last Name:VONTRELLE
Suffix:
Gender:F
Credentials:ADDICTIONS COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10999 REED HARTMAN HWY STE 108H
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-8302
Mailing Address - Country:US
Mailing Address - Phone:513-617-6683
Mailing Address - Fax:
Practice Address - Street 1:10999 REED HARTMAN HWY STE 108H
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-8302
Practice Address - Country:US
Practice Address - Phone:513-617-6683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-13
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH170910101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)