Provider Demographics
NPI:1932769742
Name:ELICK, LYDIA JANE (LSW, CDCA)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:JANE
Last Name:ELICK
Suffix:
Gender:F
Credentials:LSW, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1852 HORSESHOE BEND DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-6922
Mailing Address - Country:US
Mailing Address - Phone:419-309-4081
Mailing Address - Fax:
Practice Address - Street 1:1757 INDIAN WOOD CIR
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-4009
Practice Address - Country:US
Practice Address - Phone:866-688-6917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
OHS.2106719104100000X
OHCDCA.169902171M00000X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator