Healthcare Provider Details

I. General information

NPI: 1194454116
Provider Name (Legal Business Name): HYCIANNA AYANA GRACE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2022
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 S MERIDIAN RD
YOUNGSTOWN OH
44509-2925
US

IV. Provider business mailing address

238 S MERIDIAN RD
YOUNGSTOWN OH
44509-2925
US

V. Phone/Fax

Practice location:
  • Phone: 330-318-3436
  • Fax:
Mailing address:
  • Phone: 330-318-3436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: