Healthcare Provider Details

I. General information

NPI: 1063017457
Provider Name (Legal Business Name): NICOLE HORNBECK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 W JOHNSTOWN RD
GAHANNA OH
43230-2731
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9056
US

V. Phone/Fax

Practice location:
  • Phone: 614-729-2024
  • Fax: 614-729-2030
Mailing address:
  • Phone: 419-695-8010
  • Fax: 419-932-6232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number172665
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: