Basic Information
| Provider Information | |||||||||
| NPI: | 1720648975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DICKMAN | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1565 BETHEL RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432202005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144593003 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7100 GRAPHICS WAY STE 3100 | ||||||||
| Address2: | |||||||||
| City: | LEWIS CENTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430351123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404280428 | ||||||||
| FaxNumber: | 7409094077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2019 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | C.1801491 | OH | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.