Provider Demographics
NPI:1700431277
Name:BOUCK, NYCOLA ANN (MSW LISW-S)
Entity Type:Individual
Prefix:MRS
First Name:NYCOLA
Middle Name:ANN
Last Name:BOUCK
Suffix:
Gender:F
Credentials:MSW LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HURON
Mailing Address - State:OH
Mailing Address - Zip Code:44839-1610
Mailing Address - Country:US
Mailing Address - Phone:419-359-0307
Mailing Address - Fax:
Practice Address - Street 1:348 MAIN ST
Practice Address - Street 2:
Practice Address - City:HURON
Practice Address - State:OH
Practice Address - Zip Code:44839-1610
Practice Address - Country:US
Practice Address - Phone:419-359-0307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0800023-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical