Provider Demographics
NPI:1033822242
Name:RADWANCKY, LORI JEAN (PRS)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:JEAN
Last Name:RADWANCKY
Suffix:
Gender:F
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12345 CLARIDON TROY RD
Mailing Address - Street 2:
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-8445
Mailing Address - Country:US
Mailing Address - Phone:440-228-3379
Mailing Address - Fax:
Practice Address - Street 1:7301 RAVENNA RD
Practice Address - Street 2:
Practice Address - City:CONCORD TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:44077-8928
Practice Address - Country:US
Practice Address - Phone:440-205-2684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.003762101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)