Healthcare Provider Details

I. General information

NPI: 1700431277
Provider Name (Legal Business Name): NYCOLA ANN BOUCK MSW LISW-S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 MAIN ST
HURON OH
44839-1610
US

IV. Provider business mailing address

348 MAIN ST
HURON OH
44839-1610
US

V. Phone/Fax

Practice location:
  • Phone: 419-359-0307
  • Fax:
Mailing address:
  • Phone: 419-359-0307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.0800023-SUPV
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: