Provider Demographics
NPI:1265946305
Name:WALKER, NICOLE DEREESE (CT /CDCA)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:DEREESE
Last Name:WALKER
Suffix:
Gender:F
Credentials:CT /CDCA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DEREESE
Other - Last Name:SUTTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2149 COLLINGWOOD. BLVD.
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43620-1562
Mailing Address - Country:US
Mailing Address - Phone:419-243-9178
Mailing Address - Fax:419-243-4450
Practice Address - Street 1:2149 COLLINGWOOD. BLVD.
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43620-1562
Practice Address - Country:US
Practice Address - Phone:419-243-9178
Practice Address - Fax:419-243-4450
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1901984-TRNE1041C0700X
OH171M00000X
OHCDCA-168151101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator