Healthcare Provider Details

I. General information

NPI: 1659058709
Provider Name (Legal Business Name): AYKNEPHRA VICKERS CDCA, CPRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 STATE ROUTE 39
SHELBY OH
44875-9466
US

IV. Provider business mailing address

5413 OAKWOOD AVE
MAPLE HEIGHTS OH
44137-2376
US

V. Phone/Fax

Practice location:
  • Phone: 800-680-5747
  • Fax:
Mailing address:
  • Phone: 216-318-7264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.184197
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.003786
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: