Provider Demographics
NPI:1629115274
Name:FRIDAS, NICOLE STACI (TSHH, MSED, PD - SAS)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:STACI
Last Name:FRIDAS
Suffix:
Gender:F
Credentials:TSHH, MSED, PD - SAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SADDLER CT
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-4200
Mailing Address - Country:US
Mailing Address - Phone:631-805-8577
Mailing Address - Fax:
Practice Address - Street 1:33 WALT WHITMAN RD
Practice Address - Street 2:STE 300B
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-3640
Practice Address - Country:US
Practice Address - Phone:631-385-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33807061171M00000X
NY13637062174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered171M00000XOther Service ProvidersCase Manager/Care Coordinator
Not Answered174400000XOther Service ProvidersSpecialist