Provider Demographics
NPI:1104110634
Name:TYCAST, MEGHANN FAY
Entity type:Individual
Prefix:
First Name:MEGHANN
Middle Name:FAY
Last Name:TYCAST
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 1:1865 N RIDGE RD E STE A
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44055-3359
Mailing Address - Country:US
Mailing Address - Phone:440-324-1300
Mailing Address - Fax:
Practice Address - Street 1:1865 N RIDGE RD E STE A
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055-3359
Practice Address - Country:US
Practice Address - Phone:440-324-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2069738Medicaid