Provider Demographics
NPI:1447704416
Name:QUENNEVILLE, NICOLE (LPCC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:QUENNEVILLE
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5241 MONTGOMERY ROAD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-1655
Mailing Address - Country:US
Mailing Address - Phone:216-225-4464
Mailing Address - Fax:
Practice Address - Street 1:5241 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45212-1655
Practice Address - Country:US
Practice Address - Phone:513-993-5241
Practice Address - Fax:513-586-2768
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-08
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.141170101YA0400X
OHLICDC.161597101YP2500X
OHE.1300209-SUPV101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0214186Medicaid