Basic Information
| Provider Information | |||||||||
| NPI: | 1659877710 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZICKAFOOSE | ||||||||
| FirstName: | CONNIE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | LCDCII | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224 COLUMBUS RD | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457011334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405926724 | ||||||||
| FaxNumber: | 7405926728 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MC ARTHUR | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456511015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405962542 | ||||||||
| FaxNumber: | 7405962516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2018 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 131171 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 2864002 | 05 | OH | MEDICAID |