Provider Demographics
NPI:1356015515
Name:MOWBRAY, NICOLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:MOWBRAY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 NEWBERRY CT
Mailing Address - Street 2:
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342-9524
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 NEWBERRY CT
Practice Address - Street 2:
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-9524
Practice Address - Country:US
Practice Address - Phone:610-764-7899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS019273103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPS019273OtherLICENSE