Healthcare Provider Details

I. General information

NPI: 1952959835
Provider Name (Legal Business Name): NICOLE DAWN HARTLEBEN CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2019
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

342 MUSKINGUM DR
MARIETTA OH
45750-1435
US

IV. Provider business mailing address

119 SYLVAN WAY
MARIETTA OH
45750-5434
US

V. Phone/Fax

Practice location:
  • Phone: 800-321-8293
  • Fax:
Mailing address:
  • Phone: 740-629-8414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.171419
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2005603
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: