Provider Demographics
NPI:1770986846
Name:WILL, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WILL
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 1:1215 SPRING ASH DR
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45458-4756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:306 E WHITTIER AVE
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-5313
Practice Address - Country:US
Practice Address - Phone:937-878-3961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3053588103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool