Provider Demographics
NPI:1740644079
Name:VALENTINE, NICOLLE RACHELLE (LCDCIII)
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:RACHELLE
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 PARK AVE W
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44902-1714
Mailing Address - Country:US
Mailing Address - Phone:419-522-5015
Mailing Address - Fax:419-522-5017
Practice Address - Street 1:13 PARK AVE W
Practice Address - Street 2:SUITE 400
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44902-1714
Practice Address - Country:US
Practice Address - Phone:419-522-5015
Practice Address - Fax:419-522-5017
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH151238101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)