Provider Demographics
NPI:1275810624
Name:MAYO, NICOLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:MAYO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MAYO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:948 48TH ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2918
Mailing Address - Country:US
Mailing Address - Phone:718-283-7403
Mailing Address - Fax:
Practice Address - Street 1:948 48TH ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2918
Practice Address - Country:US
Practice Address - Phone:718-283-7403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY020384103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program