Basic Information
Provider Information
NPI: 1548400583
EntityType: 2
ReplacementNPI:  
OrganizationName: DEBORAH KORICKE, PHD AND ASSOCIATES, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 20800 CENTER RIDGE RD STE 105
Address2:  
City: ROCKY RIVER
State: OH
PostalCode: 441164314
CountryCode: US
TelephoneNumber: 4403334949
FaxNumber: 4403335044
Practice Location
Address1: 20800 CENTER RIDGE RD STE 105
Address2:  
City: ROCKY RIVER
State: OH
PostalCode: 441164314
CountryCode: US
TelephoneNumber: 4403334949
FaxNumber: 4403335044
Other Information
ProviderEnumerationDate: 03/04/2009
LastUpdateDate: 03/04/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: KORICKE
AuthorizedOfficialFirstName: DEBORAH
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 4403334949
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: PHD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500XE0001805OHN193400000X MULTIPLE SINGLE SPECIALTY GROUPBehavioral Health & Social Service ProvidersCounselorProfessional
103TC0700X3304OHY193400000X MULTIPLE SINGLE SPECIALTY GROUPBehavioral Health & Social Service ProvidersPsychologistClinical

ID Information
IDTypeStateIssuerDescription
070425005OH MEDICAID


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