Healthcare Provider Details

I. General information

NPI: 1891047775
Provider Name (Legal Business Name): NICOLE A CAVENDER MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S WASHINGTON ST
MARION IN
46952-3867
US

IV. Provider business mailing address

101 S WASHINGTON ST
MARION IN
46952-3867
US

V. Phone/Fax

Practice location:
  • Phone: 765-662-9971
  • Fax: 765-651-6563
Mailing address:
  • Phone: 765-662-9971
  • Fax: 765-651-6563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401019848
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: