Provider Demographics
NPI:1225577133
Name:COAXUM, NICOLE (MS)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:COAXUM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 LOCKWOOD AVE
Mailing Address - Street 2:2F
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-5032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2090 ADAM CLAYTON POWELL JR BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-4990
Practice Address - Country:US
Practice Address - Phone:718-514-5413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional