Provider Demographics
NPI:1932689692
Name:CHMURA, NICK MARTIN (LPC)
Entity Type:Individual
Prefix:
First Name:NICK
Middle Name:MARTIN
Last Name:CHMURA
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1662 MARS AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3825
Mailing Address - Country:US
Mailing Address - Phone:216-282-3838
Mailing Address - Fax:
Practice Address - Street 1:1662 MARS AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3825
Practice Address - Country:US
Practice Address - Phone:216-282-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0309253Medicaid