Provider Demographics
NPI:1386811552
Name:WILEY, NICOLE E (LISW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:WILEY
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3008 WALBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-5555
Mailing Address - Country:US
Mailing Address - Phone:216-647-8655
Mailing Address - Fax:
Practice Address - Street 1:10000 BRECKSVILLE RD
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-3204
Practice Address - Country:US
Practice Address - Phone:440-526-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0800306284300000X
OHI.10001131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI.1000113OtherLICENSED INDEPENDENT SOCIAL WORKER
OHS0800306OtherLICENSED SOCIAL WORKER