Provider Demographics
NPI:1053055855
Name:NICHOLSON, DONALD GENE
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:GENE
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 WAVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-3196
Mailing Address - Country:US
Mailing Address - Phone:732-233-8363
Mailing Address - Fax:
Practice Address - Street 1:628 WAVERLY AVE
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-3196
Practice Address - Country:US
Practice Address - Phone:732-233-8363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL04689700104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker