Provider Demographics
NPI:1518458801
Name:NICODEMO, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:NICODEMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 LAUREL OAK RD
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4453
Mailing Address - Country:US
Mailing Address - Phone:844-542-2273
Mailing Address - Fax:
Practice Address - Street 1:333 LAUREL OAK RD
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043
Practice Address - Country:US
Practice Address - Phone:844-542-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC057751001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty