Provider Demographics
NPI:1023434008
Name:SANSONE, NICHOLAS J (CSW, LICDC, CADC)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:J
Last Name:SANSONE
Suffix:
Gender:M
Credentials:CSW, LICDC, CADC
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:SANSONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CSW, LICDC
Mailing Address - Street 1:PO BOX 776347
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6347
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:676 S FLOYD ST LOWR LEVEL
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1840
Practice Address - Country:US
Practice Address - Phone:502-629-2500
Practice Address - Fax:502-629-2055
Is Sole Proprietor?:No
Enumeration Date:2014-03-13
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121116101YA0400X
KY253535104100000X
KY2574161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1023434008Medicaid