Healthcare Provider Details

I. General information

NPI: 1487149605
Provider Name (Legal Business Name): TINA JOY ZICKEFOOSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2018
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 SPINK ST
WOOSTER OH
44691-3652
US

IV. Provider business mailing address

104 SPINK ST
WOOSTER OH
44691-3652
US

V. Phone/Fax

Practice location:
  • Phone: 330-264-3777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number140173
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: