Provider Demographics
NPI:1386452795
Name:PORACAN, LYKAR GUDMALIN
Entity type:Individual
Prefix:
First Name:LYKAR
Middle Name:GUDMALIN
Last Name:PORACAN
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 1:6460 HARRISON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7958
Mailing Address - Country:US
Mailing Address - Phone:513-941-4999
Mailing Address - Fax:
Practice Address - Street 1:1718 CENTRAL PKWY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45214-2355
Practice Address - Country:US
Practice Address - Phone:513-941-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-19
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.190574101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0085861Medicaid