MEDICARE: ZACHERY T NICOLOSI QMHS CMS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator		OH
2	251S00000X	Community/Behavioral Health Agency		OH

General Provider Information

NPI Number	:	1356905889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ZACHERY T NICOLOSI QMHS CMS

Provider Business Mailing Address
First Line	:	434 EASTLAND RD
Second Line	:
City	:	BEREA
State	:	OH
Zip	:	44017-1217
Country	:	US
Telephone Number	:	400-234-2006
Fax Number	:

Provider Business Practice Location Address
First Line	:	1199 DELAWARE AVE STE 107
Second Line	:
City	:	MARION
State	:	OH
Zip	:	43302-7462
Country	:	US
Telephone Number	:	440-260-8300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/30/2019
Last Update Date	:	04/30/2019

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