Provider Demographics
NPI:1629518584
Name:BACK, ALICIA (LPCC)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:BACK
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45044-4103
Mailing Address - Country:US
Mailing Address - Phone:513-737-1247
Mailing Address - Fax:513-737-1239
Practice Address - Street 1:1239 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-4103
Practice Address - Country:US
Practice Address - Phone:513-737-1247
Practice Address - Fax:513-737-1239
Is Sole Proprietor?:No
Enumeration Date:2017-02-27
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1200715-SUPV101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0207830Medicaid