Provider Demographics
NPI:1912477688
Name:DEMATTEIS, NICOLE M (CDCA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:DEMATTEIS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1372 ROBBINS AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:OH
Mailing Address - Zip Code:44446-3751
Mailing Address - Country:US
Mailing Address - Phone:330-953-0243
Mailing Address - Fax:
Practice Address - Street 1:960 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4220
Practice Address - Country:US
Practice Address - Phone:330-953-0243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH168620101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)