Healthcare Provider Details

I. General information

NPI: 1770301673
Provider Name (Legal Business Name): NICOLE BAUM LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 MEDINA RD
MEDINA OH
44256-5333
US

IV. Provider business mailing address

1621 MEDINA RD
MEDINA OH
44256-5333
US

V. Phone/Fax

Practice location:
  • Phone: 330-241-4444
  • Fax:
Mailing address:
  • Phone: 330-241-4444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2614625
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: