Healthcare Provider Details

I. General information

NPI: 1932739216
Provider Name (Legal Business Name): MS. SHAVELLE MARIE LAKOVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2020
Last Update Date: 01/25/2020
Certification Date: 01/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 WOODLAND ST NE
WARREN OH
44483-5348
US

IV. Provider business mailing address

6607 COVINGTON CV
CANFIELD OH
44406-8162
US

V. Phone/Fax

Practice location:
  • Phone: 330-469-6777
  • Fax:
Mailing address:
  • Phone: 330-402-9662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: