Provider Demographics
NPI:1609483122
Name:NUSSBAUM, PEYTON MICHELE
Entity Type:Individual
Prefix:
First Name:PEYTON
Middle Name:MICHELE
Last Name:NUSSBAUM
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 1:2000 NOBLE DR
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-5353
Mailing Address - Country:US
Mailing Address - Phone:330-264-3232
Mailing Address - Fax:
Practice Address - Street 1:3402 WENGER RD S
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:OH
Practice Address - Zip Code:44618-9741
Practice Address - Country:US
Practice Address - Phone:330-749-4188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-29
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPP-000390437104100000X
OHS.2106572104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0020075941EOtherAULTCARE