Provider Demographics
NPI:1578218913
Name:BROWNBACK, NICOLE (LSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:BROWNBACK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:281 E EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:WEST GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19390-1027
Mailing Address - Country:US
Mailing Address - Phone:610-234-2913
Mailing Address - Fax:
Practice Address - Street 1:281 E EVERGREEN ST
Practice Address - Street 2:
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390-1027
Practice Address - Country:US
Practice Address - Phone:610-234-2913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW127884104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker