Provider Demographics
NPI:1942909817
Name:FORNALSKI, NICOLE M (PSYD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:FORNALSKI
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-7604
Mailing Address - Fax:614-293-3809
Practice Address - Street 1:480 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1229
Practice Address - Country:US
Practice Address - Phone:614-293-7604
Practice Address - Fax:614-293-3809
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHP.08416103G00000X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0015860Medicaid