Healthcare Provider Details

I. General information

NPI: 1467144600
Provider Name (Legal Business Name): NIKOLE MACK COUNSELOR TRAINEE CT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3951 ROCKY RIVER DR
CLEVELAND OH
44111-4154
US

IV. Provider business mailing address

5445 SMITH RD
BROOKPARK OH
44142-2026
US

V. Phone/Fax

Practice location:
  • Phone: 216-332-9360
  • Fax:
Mailing address:
  • Phone: 216-332-9360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberC.2304902-TRNE
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPP000695832
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberAPP000695832
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: