Healthcare Provider Details

I. General information

NPI: 1457857286
Provider Name (Legal Business Name): NICOLE TRENACE SCRUGGS-JOHNSON LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6279 FRANK AVE NW
NORTH CANTON OH
44720-7227
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9056
US

V. Phone/Fax

Practice location:
  • Phone: 330-305-1668
  • Fax: 330-305-1696
Mailing address:
  • Phone: 419-695-8010
  • Fax: 419-695-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS1502531
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: