Provider Demographics
NPI:1952959835
Name:HARTLEBEN, NICOLE DAWN (CDCA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DAWN
Last Name:HARTLEBEN
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 1:119 SYLVAN WAY
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-5434
Mailing Address - Country:US
Mailing Address - Phone:740-629-8414
Mailing Address - Fax:
Practice Address - Street 1:342 MUSKINGUM DR
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1435
Practice Address - Country:US
Practice Address - Phone:800-321-8293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2005603104100000X
OHCDCA.171419101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH81-1385014Medicaid