Provider Demographics
NPI:1639166051
Name:FLORES-MCCUNE, NICOLE (LISW-S)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:FLORES-MCCUNE
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9895 HUFFMAN RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:OH
Mailing Address - Zip Code:43451-9739
Mailing Address - Country:US
Mailing Address - Phone:419-575-7776
Mailing Address - Fax:
Practice Address - Street 1:10951 E GYPSY LANE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-9565
Practice Address - Country:US
Practice Address - Phone:419-913-4255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS00031519104100000X
OHI. 0700121.SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker