Provider Demographics
NPI:1558495770
Name:ECONOMOU, NICK (EDD)
Entity Type:Individual
Prefix:MR
First Name:NICK
Middle Name:
Last Name:ECONOMOU
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 LAMDAN LN
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-2709
Mailing Address - Country:US
Mailing Address - Phone:732-341-1777
Mailing Address - Fax:732-341-1075
Practice Address - Street 1:214 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-7569
Practice Address - Country:US
Practice Address - Phone:732-341-1777
Practice Address - Fax:732-341-1075
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00135500103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ439977Medicare ID - Type UnspecifiedMEDICARE PROVIDER ID#