Healthcare Provider Details

I. General information

NPI: 1659877710
Provider Name (Legal Business Name): CONNIE R ZICKAFOOSE LCDCII
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 W MAIN ST
MC ARTHUR OH
45651-1015
US

IV. Provider business mailing address

224 COLUMBUS RD
ATHENS OH
45701-1334
US

V. Phone/Fax

Practice location:
  • Phone: 740-596-2542
  • Fax: 740-596-2516
Mailing address:
  • Phone: 740-592-6724
  • Fax: 740-592-6728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number131171
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: