Healthcare Provider Details

I. General information

NPI: 1003222423
Provider Name (Legal Business Name): SHEA KVACHUK LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 WILMINGTON AVE
DAYTON OH
45420-1684
US

IV. Provider business mailing address

1105 WILMINGTON AVE
DAYTON OH
45420-1684
US

V. Phone/Fax

Practice location:
  • Phone: 937-253-0606
  • Fax:
Mailing address:
  • Phone: 937-253-0606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE.2606842
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: