Provider Demographics
NPI:1710728944
Name:NICKOLICH, NICOLE ELIZABETH (LSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:NICKOLICH
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 E MULBERRY DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18337-7216
Mailing Address - Country:US
Mailing Address - Phone:570-618-3223
Mailing Address - Fax:
Practice Address - Street 1:1300 OLD PLANK RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:PA
Practice Address - Zip Code:18433-1973
Practice Address - Country:US
Practice Address - Phone:570-281-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-03
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW141526104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker