Provider Demographics
NPI:1659877710
Name:ZICKAFOOSE, CONNIE R (LCDCII)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:R
Last Name:ZICKAFOOSE
Suffix:
Gender:F
Credentials:LCDCII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 COLUMBUS RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1334
Mailing Address - Country:US
Mailing Address - Phone:740-592-6724
Mailing Address - Fax:740-592-6728
Practice Address - Street 1:320 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MC ARTHUR
Practice Address - State:OH
Practice Address - Zip Code:45651-1015
Practice Address - Country:US
Practice Address - Phone:740-596-2542
Practice Address - Fax:740-596-2516
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH131171101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2864002Medicaid