Provider Demographics
NPI:1043623374
Name:LOFTON, NICHOLE (ED S)
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:
Last Name:LOFTON
Suffix:
Gender:F
Credentials:ED S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9728 E NORTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OLMSTED FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44138-2806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4600 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-2215
Practice Address - Country:US
Practice Address - Phone:216-631-1528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1272356103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH235Z00000XMedicaid