Basic Information
| Provider Information | |||||||||
| NPI: | 1952819997 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LINCKS | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | AMBER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CDCA, LPN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LINCKS | ||||||||
| OtherFirstName: | SUSAN | ||||||||
| OtherMiddleName: | AMBER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 245 CARTERS GROVE RD | ||||||||
| Address2: | |||||||||
| City: | CENTERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454592560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4977 NORTHCUTT PL | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454143839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373876395 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2018 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CDCA.180766 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101Y00000X | CDCA.165252 | OH | N | Behavioral Health & Social Service Providers | Counselor | 164W00000X | LPN.138775.MEDS.IV | OH | N | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.