Provider Demographics
NPI:1770054231
Name:GRAVES, NICHOLE M (PEER RECOVERY SUPPOR)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:M
Last Name:GRAVES
Suffix:
Gender:F
Credentials:PEER RECOVERY SUPPOR
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:M
Other - Last Name:MATTHEWS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2587 BACK ORRVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-9523
Mailing Address - Country:US
Mailing Address - Phone:330-264-9597
Mailing Address - Fax:330-264-0946
Practice Address - Street 1:2587 BACK ORRVILLE RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-9523
Practice Address - Country:US
Practice Address - Phone:330-264-9597
Practice Address - Fax:330-264-0946
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH000879175T00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer Specialist