Healthcare Provider Details

I. General information

NPI: 1912311937
Provider Name (Legal Business Name): KATINA NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7232 JUSTIN WAY
MENTOR OH
44060-4881
US

IV. Provider business mailing address

2645 BLUE HERON DR
HUDSON OH
44236-1868
US

V. Phone/Fax

Practice location:
  • Phone: 440-578-8200
  • Fax:
Mailing address:
  • Phone: 443-226-9791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number0
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: