Provider Demographics
NPI:1104521558
Name:GOODWILL, NICOLE MARIE (CDCA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:GOODWILL
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 1/2 N CUMBERLAND ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45814-8791
Mailing Address - Country:US
Mailing Address - Phone:937-209-1215
Mailing Address - Fax:
Practice Address - Street 1:905 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FINDLAY
Practice Address - State:OH
Practice Address - Zip Code:45840-3670
Practice Address - Country:US
Practice Address - Phone:567-525-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHAPS.003604175T00000X
OHCDCA187534101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty