Provider Demographics
NPI:1366628216
Name:LASELLE, NICOLE MARIE (PCC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:LASELLE
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5338 MEADOW LANE CT
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44035-1469
Mailing Address - Country:US
Mailing Address - Phone:216-282-3838
Mailing Address - Fax:
Practice Address - Street 1:5338 MEADOW LANE CT
Practice Address - Street 2:
Practice Address - City:SHEFFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44035-1469
Practice Address - Country:US
Practice Address - Phone:216-282-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE. 0007949101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0256683Medicaid