MEDICARE: LAKETRA CHICK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	S1502344	OH

General Provider Information

NPI Number	:	1053772137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKETRA CHICK

Provider Business Mailing Address
First Line	:	3325 GLENMORE AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45211-6510
Country	:	US
Telephone Number	:	513-231-6630
Fax Number	:

Provider Business Practice Location Address
First Line	:	3325 GLENMORE AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45211
Country	:	US
Telephone Number	:	513-231-6630
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2016
Last Update Date	:	07/11/2018

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Directions to “ LAKETRA CHICK ” Practice Location

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