Provider Demographics
NPI:1235526096
Name:WILDROUDT, NICOLE R (LICDC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:WILDROUDT
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S EDWIN C MOSES BLVD
Mailing Address - Street 2:SAMARITAN BEHAVIORAL HEALTH, INC., 4TH FLOOR, NW BLDG
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-3424
Mailing Address - Country:US
Mailing Address - Phone:937-734-8333
Mailing Address - Fax:937-734-8252
Practice Address - Street 1:601 S EDWIN C MOSES BLVD
Practice Address - Street 2:SAMARITAN BEHAVIORAL HEALTH, INC. 1ST FLOOR, NW BLDG
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3424
Practice Address - Country:US
Practice Address - Phone:937-734-9482
Practice Address - Fax:937-224-1625
Is Sole Proprietor?:No
Enumeration Date:2015-04-20
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHLICDC.162012101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator