Provider Demographics
NPI:1902431778
Name:PELLIGRA, NICHOLAS (LCSW)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:PELLIGRA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 RIVER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1016
Mailing Address - Country:US
Mailing Address - Phone:201-606-2592
Mailing Address - Fax:
Practice Address - Street 1:103 RIVER RD STE 101
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1016
Practice Address - Country:US
Practice Address - Phone:201-606-2592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC058955001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ44SC05895500OtherSTATE LICENSE