Provider Demographics
NPI:1194324988
Name:VISCONTI, NINA ELISE (CT)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:ELISE
Last Name:VISCONTI
Suffix:
Gender:F
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 VINCENT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44067-1240
Mailing Address - Country:US
Mailing Address - Phone:440-785-6959
Mailing Address - Fax:
Practice Address - Street 1:3737 LANDER RD
Practice Address - Street 2:
Practice Address - City:PEPPER PIKE
Practice Address - State:OH
Practice Address - Zip Code:44124-5712
Practice Address - Country:US
Practice Address - Phone:216-831-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
OHC.2002843--TRNE101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2871101Medicaid