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NPI Code Detail

MEDICARE: NIKOLE MACK COUNSELOR TRAINEE CT

MEDICARE: NIKOLE MACK COUNSELOR TRAINEE CT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior TechnicianAPP000695832OH
2175T00000XPeer SpecialistAPP000695832OH
3101Y00000XCounselorC.2304902-TRNEOH

General Provider Information

NPI Number : 1467144600
Entity Type Code : Individual
Provider Name (Legal Business Name) : NIKOLE MACK COUNSELOR TRAINEE CT
Provider Business Mailing Address
First Line : 5445 SMITH RD
Second Line :
City : BROOKPARK
State : OH
Zip : 44142-2026
Country : US
Telephone Number : 216-332-9360
Fax Number :
Provider Business Practice Location Address
First Line : 3951 ROCKY RIVER DR
Second Line :
City : CLEVELAND
State : OH
Zip : 44111-4154
Country : US
Telephone Number : 216-332-9360
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/25/2023
Last Update Date : 04/19/2024

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Directions to “ NIKOLE MACK COUNSELOR TRAINEE CT” Practice Location

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