Basic Information
| Provider Information | |||||||||
| NPI: | 1366628216 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LASELLE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5338 MEADOW LANE CT | ||||||||
| Address2: | |||||||||
| City: | SHEFFIELD VILLAGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440351469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162823838 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5338 MEADOW LANE CT | ||||||||
| Address2: | |||||||||
| City: | SHEFFIELD VILLAGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440351469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162823838 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2008 | ||||||||
| LastUpdateDate: | 10/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | E. 0007949 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 0256683 | 05 | OH | MEDICAID |