Healthcare Provider Details

I. General information

NPI: 1215421300
Provider Name (Legal Business Name): KYLE J NICHOL CDCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 W MAIN ST
SAINT CLAIRSVILLE OH
43950-1040
US

IV. Provider business mailing address

P.O. BOX 118
SAINT CLAIRSVILLE OH
43950-0118
US

V. Phone/Fax

Practice location:
  • Phone: 740-695-9447
  • Fax: 740-968-7256
Mailing address:
  • Phone: 740-695-9447
  • Fax: 740-695-8895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number178346
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: