Provider Demographics
NPI:1891213294
Name:PODGORSKI, NICOLE MARY (LISW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARY
Last Name:PODGORSKI
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 1:7055 ENGLE RD BLDG 6-601
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-8491
Mailing Address - Country:US
Mailing Address - Phone:440-610-7733
Mailing Address - Fax:
Practice Address - Street 1:7055 ENGLE RD BLDG 6-601
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-8491
Practice Address - Country:US
Practice Address - Phone:440-610-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2025-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LICDC.162430101YA0400X
OH1600701104100000X
OHI.25068721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0262708Medicaid