Healthcare Provider Details

I. General information

NPI: 1396493953
Provider Name (Legal Business Name): NICOLE ANN THOMPSON LCDCIII. 162583
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2022
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 PARK AVE W
MANSFIELD OH
44906-3702
US

IV. Provider business mailing address

1050 KINGSMILL PKWY
COLUMBUS OH
43229-1143
US

V. Phone/Fax

Practice location:
  • Phone: 833-762-1013
  • Fax: 617-591-3893
Mailing address:
  • Phone: 614-907-5434
  • Fax: 614-939-2357

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.141536
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCIII.162583
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: