Provider Demographics
NPI:1508083916
Name:NICODEMUS, DAVID EDWARD JR (MA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:EDWARD
Last Name:NICODEMUS
Suffix:JR
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19605-1102
Mailing Address - Country:US
Mailing Address - Phone:610-921-3172
Mailing Address - Fax:
Practice Address - Street 1:1623 MORGANTOWN RD
Practice Address - Street 2:HEALTHSOUTH READING REHABILITATION HOSPITAL
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19607-9455
Practice Address - Country:US
Practice Address - Phone:610-796-6422
Practice Address - Fax:610-796-6306
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007441L103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical