1023434008 NPI number — MR. NICHOLAS J SANSONE CSW, LICDC, CADC

Table of content: MR. NICHOLAS J SANSONE CSW, LICDC, CADC (NPI 1023434008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023434008 NPI number — MR. NICHOLAS J SANSONE CSW, LICDC, CADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SANSONE
Provider First Name:
NICHOLAS
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CSW, LICDC, CADC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SANSONE
Provider Other First Name:
NICK
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CSW, LICDC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1023434008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776347
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6347
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-588-9490
Provider Business Mailing Address Fax Number:
502-272-5339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
676 S FLOYD ST LOWR LEVEL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40202-1840
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-629-2500
Provider Business Practice Location Address Fax Number:
502-629-2055
Provider Enumeration Date:
03/13/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  121116 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X , with the licence number: 253535 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 257416 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1023434008 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".