Provider Demographics
NPI:1841069150
Name:ICEMAN, SYDNEY TAYLOR
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:TAYLOR
Last Name:ICEMAN
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 1:1742 GEORGETOWN RD STE AANDB
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-5006
Mailing Address - Country:US
Mailing Address - Phone:330-603-8534
Mailing Address - Fax:
Practice Address - Street 1:1742 GEORGETOWN RD STE AANDB
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44236-5006
Practice Address - Country:US
Practice Address - Phone:330-603-8534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-22-211330106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician