Provider Demographics
NPI:1619542545
Name:SJOSTROM, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SJOSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:DOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:419 N FRANKLIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-2400
Mailing Address - Country:US
Mailing Address - Phone:267-243-5970
Mailing Address - Fax:
Practice Address - Street 1:419 N FRANKLIN ST STE 2
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-2400
Practice Address - Country:US
Practice Address - Phone:267-243-5970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH005295103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1124667456Medicaid