Provider Demographics
NPI:1093118820
Name:STREETS, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:STREETS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:549 E HIGH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-1141
Mailing Address - Country:US
Mailing Address - Phone:267-235-2039
Mailing Address - Fax:
Practice Address - Street 1:551 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:HAVERFORD
Practice Address - State:PA
Practice Address - Zip Code:19041-1419
Practice Address - Country:US
Practice Address - Phone:610-526-1974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health