Provider Demographics
NPI:1124522727
Name:EGGER, NICOLE K (CDCA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:K
Last Name:EGGER
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 1:224 COLUMBUS RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1334
Mailing Address - Country:US
Mailing Address - Phone:740-592-6724
Mailing Address - Fax:740-592-6728
Practice Address - Street 1:12896 GREY ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-9638
Practice Address - Country:US
Practice Address - Phone:740-380-6354
Practice Address - Fax:740-380-3592
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH165493101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2314525Medicaid