Provider Demographics
NPI:1205858180
Name:NICOLOFF, LEE KATHERINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:KATHERINE
Last Name:NICOLOFF
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 COYLE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-4006
Mailing Address - Country:US
Mailing Address - Phone:207-799-1441
Mailing Address - Fax:207-879-5969
Practice Address - Street 1:186 COYLE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-4006
Practice Address - Country:US
Practice Address - Phone:207-799-1441
Practice Address - Fax:207-879-5969
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-23
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS632103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM5442Medicare ID - Type Unspecified