Healthcare Provider Details

I. General information

NPI: 1720510589
Provider Name (Legal Business Name): LAYLA MELISSA ZICKEFOOSE LCSW, LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W WENGER RD STE B
ENGLEWOOD OH
45322-2761
US

IV. Provider business mailing address

PO BOX 106
BROOKVILLE OH
45309-0106
US

V. Phone/Fax

Practice location:
  • Phone: 937-886-4894
  • Fax: 937-518-7787
Mailing address:
  • Phone: 937-886-4894
  • Fax: 937-518-7787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904009783
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: