Healthcare Provider Details

I. General information

NPI: 1124737176
Provider Name (Legal Business Name): SARAH ELIZABETH LYCZKOWSKI CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2022
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6202 TRUST DR
HOLLAND OH
43528-8425
US

IV. Provider business mailing address

6202 TRUST DR
HOLLAND OH
43528-8425
US

V. Phone/Fax

Practice location:
  • Phone: 419-824-8462
  • Fax:
Mailing address:
  • Phone: 419-824-8462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number180072
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: