Provider Demographics
NPI:1518179506
Name:HAWK, CONIDA NICOLE (PCC-S)
Entity Type:Individual
Prefix:MS
First Name:CONIDA
Middle Name:NICOLE
Last Name:HAWK
Suffix:
Gender:F
Credentials:PCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4761 BURGER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-3830
Mailing Address - Country:US
Mailing Address - Phone:216-200-3675
Mailing Address - Fax:
Practice Address - Street 1:6200 ROCKSIDE WOODS BLVD N STE 305
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2343
Practice Address - Country:US
Practice Address - Phone:216-200-3675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0500928101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health