Provider Demographics
NPI:1740041789
Name:TEGTMAN, ALICIA (LSW)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:TEGTMAN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44090-1330
Mailing Address - Country:US
Mailing Address - Phone:918-934-6924
Mailing Address - Fax:
Practice Address - Street 1:22540 LORAIN RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-2212
Practice Address - Country:US
Practice Address - Phone:918-934-6924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2310239104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker