Provider Demographics
NPI:1225418114
Name:WILSON, NICHOLE (LSW)
Entity Type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24500 CENTER RIDGE RD STE 395
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5631
Mailing Address - Country:US
Mailing Address - Phone:440-455-9125
Mailing Address - Fax:
Practice Address - Street 1:24500 CENTER RIDGE RD STE 395
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-5631
Practice Address - Country:US
Practice Address - Phone:440-455-9125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1500661104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0264943Medicaid