Provider Demographics
NPI:1578834784
Name:IACOVONI, NICOLE (LCSW, MSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:IACOVONI
Suffix:
Gender:F
Credentials:LCSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17815-1752
Mailing Address - Country:US
Mailing Address - Phone:570-336-9921
Mailing Address - Fax:
Practice Address - Street 1:214 CENTER ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1752
Practice Address - Country:US
Practice Address - Phone:570-336-9921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0171381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical