Provider Demographics
NPI:1568977411
Name:SPJUT, NICHOLE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:SPJUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 ARTILLERY PARK DR UNIT 102
Mailing Address - Street 2:
Mailing Address - City:FORT MITCHELL
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2794
Mailing Address - Country:US
Mailing Address - Phone:859-429-2120
Mailing Address - Fax:
Practice Address - Street 1:305 ARTILLERY PARK DR UNIT 102
Practice Address - Street 2:
Practice Address - City:FORT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017-2794
Practice Address - Country:US
Practice Address - Phone:859-429-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
KY2554971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000OtherLICENSURE