Provider Demographics
NPI:1609561943
Name:CLEVELAND, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CLEVELAND
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 1:551 HUCKLEBERRY BUTTE RD
Mailing Address - Street 2:
Mailing Address - City:OROFINO
Mailing Address - State:ID
Mailing Address - Zip Code:83544-5083
Mailing Address - Country:US
Mailing Address - Phone:208-827-6093
Mailing Address - Fax:
Practice Address - Street 1:551 HUCKLEBERRY BUTTE RD
Practice Address - Street 2:
Practice Address - City:OROFINO
Practice Address - State:ID
Practice Address - Zip Code:83544-5083
Practice Address - Country:US
Practice Address - Phone:208-827-6093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW434111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical