Provider Demographics
NPI:1164526620
Name:GRACE, NICOLE E (LCSW, PSYA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:GRACE
Suffix:
Gender:F
Credentials:LCSW, PSYA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14-25 PLAZA RD
Mailing Address - Street 2:SUITE N 2-4
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3546
Mailing Address - Country:US
Mailing Address - Phone:201-803-9193
Mailing Address - Fax:
Practice Address - Street 1:14-25 PLAZA RD
Practice Address - Street 2:SUITE N 2-4
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3546
Practice Address - Country:US
Practice Address - Phone:201-803-9193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC046461001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ038471Medicare ID - Type Unspecified