Basic Information
| Provider Information | |||||||||
| NPI: | 1376126821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BECK | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | KRISTEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3567 ROME GREENWICH RD | ||||||||
| Address2: | |||||||||
| City: | GREENWICH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448379489 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196773454 | ||||||||
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| Practice Location | |||||||||
| Address1: | 117 BLOSSOM CENTRE BLVD | ||||||||
| Address2: | |||||||||
| City: | WILLARD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 448909317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5675603586 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2021 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | S.2106899 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.