Provider Demographics
NPI:1093460735
Name:NICKEY, TRAVELL (LCADC)
Entity Type:Individual
Prefix:
First Name:TRAVELL
Middle Name:
Last Name:NICKEY
Suffix:
Gender:M
Credentials:LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 PINEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-8026
Mailing Address - Country:US
Mailing Address - Phone:848-223-0949
Mailing Address - Fax:
Practice Address - Street 1:19 PINEVIEW DR
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-8026
Practice Address - Country:US
Practice Address - Phone:848-223-0949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00347900101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)