Healthcare Provider Details

I. General information

NPI: 1326552183
Provider Name (Legal Business Name): NICOLE KELLEHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9930 JOHNNYCAKE RIDGE RD STE 4F
MENTOR OH
44060-6762
US

IV. Provider business mailing address

9930 JOHNNYCAKE RIDGE RD STE 4F
MENTOR OH
44060-6762
US

V. Phone/Fax

Practice location:
  • Phone: 440-579-5100
  • Fax:
Mailing address:
  • Phone: 440-579-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2203556
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: