Provider Demographics
NPI:1508977018
Name:OMELTSCHENKO, LAURETTA
Entity Type:Individual
Prefix:DR
First Name:LAURETTA
Middle Name:
Last Name:OMELTSCHENKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3510 GLENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211
Mailing Address - Country:US
Mailing Address - Phone:513-481-0221
Mailing Address - Fax:513-481-0548
Practice Address - Street 1:3510 GLENMORE AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-5420
Practice Address - Country:US
Practice Address - Phone:513-481-0221
Practice Address - Fax:513-481-0548
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHF 056174400000X
OHE 1944101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered174400000XOther Service ProvidersSpecialist
Not Answered101Y00000XBehavioral Health & Social Service ProvidersCounselor