Provider Demographics
NPI:1891213294
Name:PODGORSKI, NICOLE MARY (LSW, LICDC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARY
Last Name:PODGORSKI
Suffix:
Gender:F
Credentials:LSW, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 W PARK DR
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1138
Mailing Address - Country:US
Mailing Address - Phone:440-989-4900
Mailing Address - Fax:
Practice Address - Street 1:4807 ROCKSIDE RD STE 610
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:OH
Practice Address - Zip Code:44131-2166
Practice Address - Country:US
Practice Address - Phone:216-906-1117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LICDC.162430101YA0400X
OH1600701104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0262708Medicaid