Provider Demographics
NPI:1316362866
Name:DEGRAZIA, NICHOLAS (EDS NCSP)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DEGRAZIA
Suffix:
Gender:M
Credentials:EDS NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 OLD SALEM RD
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-2681
Mailing Address - Country:US
Mailing Address - Phone:937-832-6562
Mailing Address - Fax:
Practice Address - Street 1:4001 OLD SALEM RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2681
Practice Address - Country:US
Practice Address - Phone:937-832-6562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1512627103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool