Provider Demographics
NPI:1689713174
Name:UDOLPH, NANCY J (LISW-S, PCC-S)
Entity Type:Individual
Prefix:PROF
First Name:NANCY
Middle Name:J
Last Name:UDOLPH
Suffix:
Gender:F
Credentials:LISW-S, PCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 EASTBROOK DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-3415
Mailing Address - Country:US
Mailing Address - Phone:419-289-5372
Mailing Address - Fax:
Practice Address - Street 1:19 W MAIN ST
Practice Address - Street 2:SUITE 16
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-2282
Practice Address - Country:US
Practice Address - Phone:419-651-7669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0000325101YP2500X
OHI00027981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional