Provider Demographics
NPI:1285182022
Name:CLARK, NICOLE MICHELLE (LSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:CLARK
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 1:3506 DANBURY ROAD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-5311
Mailing Address - Country:US
Mailing Address - Phone:513-382-9202
Mailing Address - Fax:
Practice Address - Street 1:1349 EAST STROOP ROAD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-4925
Practice Address - Country:US
Practice Address - Phone:937-293-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS1303565104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker