Provider Demographics
NPI:1902515893
Name:SOUZA, NICOLE B (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:B
Last Name:SOUZA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 CARLETON AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-4506
Mailing Address - Country:US
Mailing Address - Phone:631-663-4300
Mailing Address - Fax:
Practice Address - Street 1:320 CARLETON AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-4506
Practice Address - Country:US
Practice Address - Phone:631-633-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115496-01104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker