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NPI Code Detail

MEDICARE: NICOLE MARIE BENNETT CDCA.179664

MEDICARE: NICOLE MARIE BENNETT CDCA.179664
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
1101YA0400XAddiction (Substance Use Disorder) CounselorCDCA.179664OH

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1992302921
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICOLE MARIE BENNETT CDCA.179664
Provider Business Mailing Address
First Line : 3801 DENISON AVE
Second Line :
City : CLEVELAND
State : OH
Zip : 44109-2630
Country : US
Telephone Number : 216-417-4831
Fax Number : 216-417-0040
Provider Business Practice Location Address
First Line : 2121 W 117TH ST
Second Line :
City : CLEVELAND
State : OH
Zip : 44111-1642
Country : US
Telephone Number : 216-417-4831
Fax Number : 216-417-0040
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/02/2020
Last Update Date : 04/20/2023

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