Provider Demographics
NPI:1720510589
Name:ZICKEFOOSE, LAYLA MELISSA (LCSW, LISW)
Entity Type:Individual
Prefix:
First Name:LAYLA
Middle Name:MELISSA
Last Name:ZICKEFOOSE
Suffix:
Gender:F
Credentials:LCSW, LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 BRUNS DR
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45309-1112
Mailing Address - Country:US
Mailing Address - Phone:937-886-4894
Mailing Address - Fax:
Practice Address - Street 1:169 BRUNS DR
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:OH
Practice Address - Zip Code:45309-1112
Practice Address - Country:US
Practice Address - Phone:937-886-4894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-31
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040097831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical