Provider Demographics
NPI:1457042327
Name:SLACK, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2567 WHEELERS MILL RD
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-8309
Mailing Address - Country:US
Mailing Address - Phone:740-981-7342
Mailing Address - Fax:
Practice Address - Street 1:1406 11TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4247
Practice Address - Country:US
Practice Address - Phone:866-534-2639
Practice Address - Fax:800-480-7578
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X, 251B00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0017926Medicaid