Healthcare Provider Details

I. General information

NPI: 1508363748
Provider Name (Legal Business Name): LARRY SYKES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2018
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11643 TIMBER RIDGE LN APT 1
SHARONVILLE OH
45241-2313
US

IV. Provider business mailing address

11643 TIMBER RIDGE LN APT 1
SHARONVILLE OH
45241-2313
US

V. Phone/Fax

Practice location:
  • Phone: 513-702-4653
  • Fax:
Mailing address:
  • Phone: 513-702-4653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: