Healthcare Provider Details

I. General information

NPI: 1952991051
Provider Name (Legal Business Name): KENNETH JOHN KATRICAK I LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2021
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 E BROAD ST
ELYRIA OH
44035-6305
US

IV. Provider business mailing address

1131 E BROAD ST
ELYRIA OH
44035-6305
US

V. Phone/Fax

Practice location:
  • Phone: 216-270-7464
  • Fax: 440-387-4706
Mailing address:
  • Phone: 216-270-7464
  • Fax: 440-387-4706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberC1801465
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN212255
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: