Provider Demographics
NPI:1568220762
Name:MORT, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MORT
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 1:1100 SWANS WAY
Mailing Address - Street 2:
Mailing Address - City:PITTSGROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:08318-9173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 SWANS WAY
Practice Address - Street 2:
Practice Address - City:PITTSGROVE
Practice Address - State:NJ
Practice Address - Zip Code:08318-9173
Practice Address - Country:US
Practice Address - Phone:856-362-1364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC059281001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical