Provider Demographics
NPI:1285094755
Name:GESICKI, KRYSTAL L (LISW, LICDC)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:L
Last Name:GESICKI
Suffix:
Gender:F
Credentials:LISW, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24500 CENTER RIDGE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5602
Mailing Address - Country:US
Mailing Address - Phone:330-946-6925
Mailing Address - Fax:888-868-7178
Practice Address - Street 1:24500 CENTER RIDGE RD STE 120
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5602
Practice Address - Country:US
Practice Address - Phone:330-946-6925
Practice Address - Fax:888-868-7178
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1200918101YA0400X
OHLICDC.161416101YA0400X
OHI.1600727-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0192132Medicaid
OHI.1600727-SUPVOtherLICENSE
OHLICDC.161416OtherLICENSE