Provider Demographics
NPI:1063017457
Name:HORNBECK, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:HORNBECK
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 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9056
Mailing Address - Country:US
Mailing Address - Phone:419-695-8010
Mailing Address - Fax:419-932-6232
Practice Address - Street 1:212 W JOHNSTOWN RD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-2731
Practice Address - Country:US
Practice Address - Phone:614-729-2024
Practice Address - Fax:614-729-2030
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH172665101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)