| National Provider Identifier [NPI]: | 1194998179 |
| Last Name Of The Provider | NICOLET |
| First Name Of The Provider | RONALD |
| Middle Initial Of The Provider | G |
| Credentials Of The Provider | MA, LMHC, LCAC, NCC |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1910 SAINT JOE CENTER RD |
| Street Address 2 Of The Provider | SUITE 13 |
| City Of The Provider | FORT WAYNE |
| Zip Code Of The Provider | 468255000 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Licensed Clinical Social Worker |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 4 |
| Number Of Services | 1373 |
| Number Of Medicare Beneficiaries | 308 |
| Total Submitted Charge Amount | 181740 |
| Total Medicare Allowed Amount | 122049.94 |
| Total Medicare Payment Amount | 93870.79 |
| Total Medicare Standardized Payment Amount | 95796.2 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 4 |
| Number Of Medical Services | 1373 |
| Number Of Medicare Beneficiaries With Medical Services | 308 |
| Total Medical Submitted Charge Amount | 181740 |
| Total Medical Medicare Allowed Amount | 122049.94 |
| Total Medical Medicare Payment Amount | 93870.79 |
| Total Medical Medicare Standardized Payment Amount | 95796.2 |
| Average Age Of Beneficiaries | 65 |
| Number Of Beneficiaries Age Less65 | 154 |
| Number Of Beneficiaries Age 65 to 74 | 46 |
| Number Of Beneficiaries Age 75 to 84 | 52 |
| Number Of Beneficiaries Age Greater 84 | 56 |
| Number Of Female Beneficiaries | 213 |
| Number Of Male Beneficiaries | 95 |
| Number Of Non Hispanic White Beneficiaries | 285 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 71 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 237 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 36 |
| Percent Of With Asthma | 12 |
| Percent Of With Cancer | 4 |
| Percent Of With Heart Failure | 33 |
| Percent Of With Chronic Kidney Disease | 28 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 31 |
| Percent Of With Depression | 75 |
| Percent Of With Diabetes | 44 |
| Percent Of With Hyperlipidemia | 47 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 35 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 74 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 23 |
| Percent Of With Stroke | 8 |
| Average HCC Risk Score Of Beneficiaries | 1.9276 |