Basic Information
| Provider Information | |||||||||
| NPI: | 1891047775 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAVENDER | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 101 S WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469523867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656629971 | ||||||||
| FaxNumber: | 7656516563 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 S WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469523867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7656629971 | ||||||||
| FaxNumber: | 7656516563 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2012 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401019848 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1780734806 | 05 | IN | MEDICAID |