Provider Demographics
NPI:1851023386
Name:ROUSH, NIKI TAYLOR
Entity Type:Individual
Prefix:
First Name:NIKI
Middle Name:TAYLOR
Last Name:ROUSH
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 1:1865 N RIDGE RD E STE A
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44055-3359
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:440-277-0409
Practice Address - Street 1:1865 N RIDGE RD E STE A
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055-3359
Practice Address - Country:US
Practice Address - Phone:440-324-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-24
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHS.2208425104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator