Provider Demographics
NPI:1477782514
Name:ACKERMAN, NICOLE A (LISW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 LANDER RD
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5712
Mailing Address - Country:US
Mailing Address - Phone:216-831-2255
Mailing Address - Fax:216-378-3906
Practice Address - Street 1:6140 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3821
Practice Address - Country:US
Practice Address - Phone:440-233-7232
Practice Address - Fax:440-404-4315
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0500656104100000X
OHI.18013321041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHECFMGMedicaid
OH0268768Medicaid