Provider Demographics
NPI:1902233091
Name:PRIDONOFF, NINA (LSW)
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
Last Name:PRIDONOFF
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:NINA
Other - Middle Name:
Other - Last Name:SIEGAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9395 KENWOOD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-6819
Mailing Address - Country:US
Mailing Address - Phone:134-691-1885
Mailing Address - Fax:
Practice Address - Street 1:9395 KENWOOD RD STE 100
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-6819
Practice Address - Country:US
Practice Address - Phone:513-469-1188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1701323104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00089099Medicaid