Healthcare Provider Details

I. General information

NPI: 1598512741
Provider Name (Legal Business Name): CARRIE WYKRENT CDCA-PRELIMINARY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/06/2024
Certification Date: 05/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 MIDWAY BLVD
ELYRIA OH
44035-2786
US

IV. Provider business mailing address

708 LUCILLE DR
ELYRIA OH
44035-3705
US

V. Phone/Fax

Practice location:
  • Phone: 440-723-8997
  • Fax:
Mailing address:
  • Phone: 440-452-9443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.185559
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: