Provider Demographics
NPI:1467713073
Name:DERRICO, NICOLE LEIGH (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LEIGH
Last Name:DERRICO
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LEIGH
Other - Last Name:THORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:203 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NC
Mailing Address - Zip Code:28390-3902
Mailing Address - Country:US
Mailing Address - Phone:910-339-9375
Mailing Address - Fax:910-491-0077
Practice Address - Street 1:203 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-3902
Practice Address - Country:US
Practice Address - Phone:910-339-9375
Practice Address - Fax:910-491-0077
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY078863-1104100000X
NCC0101471041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY078863-1OtherLMSW
NCC010147OtherLCSW