Provider Demographics
NPI:1093252850
Name:SMITH, NICOLE DENISE (LAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:DENISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 MAIN STREET
Mailing Address - Street 2:SUITE 5 / ALLEY
Mailing Address - City:CLINTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08809
Mailing Address - Country:US
Mailing Address - Phone:908-642-8509
Mailing Address - Fax:
Practice Address - Street 1:37 MAIN STREET
Practice Address - Street 2:SUITE 5 / ALLEY
Practice Address - City:CLINTON
Practice Address - State:NJ
Practice Address - Zip Code:08809
Practice Address - Country:US
Practice Address - Phone:908-642-8509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00329700101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor