Provider Demographics
NPI:1639669294
Name:NINO, DOLORES
Entity Type:Individual
Prefix:
First Name:DOLORES
Middle Name:
Last Name:NINO
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 1:427 W TIFFIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:OH
Mailing Address - Zip Code:44890-1252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 BLOSSOM CENTRE BLVD
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:OH
Practice Address - Zip Code:44890-9317
Practice Address - Country:US
Practice Address - Phone:567-560-3586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.163843101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)