Basic Information
| Provider Information | |||||||||
| NPI: | 1770909277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REAGAN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | LISW-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 951101 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4408790081 | ||||||||
| FaxNumber: | 4408790084 | ||||||||
| Practice Location | |||||||||
| Address1: | 14519 DETROIT AVENUE | ||||||||
| Address2: | LAKEWOOD HOSPITAL | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165214200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2014 | ||||||||
| LastUpdateDate: | 03/11/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.0900290-SUPV | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.