Provider Demographics
NPI:1508369141
Name:AIRHART, NICOLLETTE ROSE (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLLETTE
Middle Name:ROSE
Last Name:AIRHART
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2686 TILTON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-4017
Mailing Address - Country:US
Mailing Address - Phone:330-495-8763
Mailing Address - Fax:
Practice Address - Street 1:1819 JOHN F KENNEDY BLVD STE 302
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-1729
Practice Address - Country:US
Practice Address - Phone:330-495-8763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0198521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical