Provider Demographics
NPI:1598451841
Name:DELAVEGA, NICHOLE C
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:C
Last Name:DELAVEGA
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 1:165 LATTINTOWN RD LOT 83
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-1091
Mailing Address - Country:US
Mailing Address - Phone:518-567-7438
Mailing Address - Fax:
Practice Address - Street 1:146 PIKE ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-1808
Practice Address - Country:US
Practice Address - Phone:845-858-1456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0951101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical