=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255193835
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICKOLE WEDDELMAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2024
-----------------------------------------------------
Last Update Date | 01/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1070 COMMERCE DR STE 101
-----------------------------------------------------
City | PERRYSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43551-5231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-482-8382
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3039 GLENCAIRN AVE
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43614-3915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-806-7145
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------