Provider Demographics
NPI:1376675595
Name:LARRICK, COLEEN D (LICDC, LPN)
Entity Type:Individual
Prefix:MRS
First Name:COLEEN
Middle Name:D
Last Name:LARRICK
Suffix:
Gender:F
Credentials:LICDC, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 ELSINORE PL STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1459
Mailing Address - Country:US
Mailing Address - Phone:513-834-7063
Mailing Address - Fax:
Practice Address - Street 1:2572 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-1882
Practice Address - Country:US
Practice Address - Phone:513-834-7063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.113413.MEDS-IV164W00000X
OHPN113413164W00000X
OHLICDC.162003101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2415738Medicaid