Provider Demographics
NPI:1598512741
Name:WYKRENT, CARRIE (CDCA-PRELIMINARY)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:WYKRENT
Suffix:
Gender:M
Credentials:CDCA-PRELIMINARY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:708 LUCILLE DR
Mailing Address - Street 2:
Mailing Address - City:ELYRIA
Mailing Address - State:OH
Mailing Address - Zip Code:44035-3705
Mailing Address - Country:US
Mailing Address - Phone:440-452-9443
Mailing Address - Fax:
Practice Address - Street 1:174 MIDWAY BLVD
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-2786
Practice Address - Country:US
Practice Address - Phone:440-723-8997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-06
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.185559101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)