=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063779676
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLE LIN NITSCHKE LPCC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2012
-----------------------------------------------------
Last Update Date | 05/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 421 W MAIN ST
-----------------------------------------------------
City | WOODVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43469-1140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-849-2414
-----------------------------------------------------
Fax | 567-342-5541
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 421 W MAIN ST
-----------------------------------------------------
City | WOODVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43469-1140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-848-2414
-----------------------------------------------------
Fax | 567-342-5541
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | E. 0007962
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | E. 0007962
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------