Provider Demographics
NPI:1417462979
Name:CLINE, NICOLE RENE (CDCA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENE
Last Name:CLINE
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:RENE
Other - Last Name:CLINE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CDCA
Mailing Address - Street 1:129 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TIRO
Mailing Address - State:OH
Mailing Address - Zip Code:44887-9796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 BLOSSOM CENTRE BLVD
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:OH
Practice Address - Zip Code:44890-9312
Practice Address - Country:US
Practice Address - Phone:567-560-3586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.165201101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)