Provider Demographics
NPI:1467144600
Name:MACK, NIKOLE (COUNSELOR TRAINEE CT)
Entity Type:Individual
Prefix:
First Name:NIKOLE
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:COUNSELOR TRAINEE CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5445 SMITH RD
Mailing Address - Street 2:
Mailing Address - City:BROOKPARK
Mailing Address - State:OH
Mailing Address - Zip Code:44142-2026
Mailing Address - Country:US
Mailing Address - Phone:216-332-9360
Mailing Address - Fax:
Practice Address - Street 1:3951 ROCKY RIVER DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-4154
Practice Address - Country:US
Practice Address - Phone:216-332-9360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPP000695832106S00000X, 175T00000X
OHC.2304902-TRNE101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No175T00000XOther Service ProvidersPeer Specialist