Provider Demographics
NPI:1043421381
Name:BECKLES, NICOLA (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICOLA
Middle Name:
Last Name:BECKLES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 85
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-0085
Mailing Address - Country:US
Mailing Address - Phone:718-390-8815
Mailing Address - Fax:718-526-5503
Practice Address - Street 1:221 BROADWAY
Practice Address - Street 2:SUITE 201C
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2780
Practice Address - Country:US
Practice Address - Phone:718-390-8815
Practice Address - Fax:718-526-5503
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009984103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01183884Medicaid
NY01183884Medicaid