Provider Demographics
NPI:1659034577
Name:MEDIATE, NICHOLAS (LPC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:MEDIATE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 FIELDSTONE TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7486
Mailing Address - Country:US
Mailing Address - Phone:570-620-6684
Mailing Address - Fax:
Practice Address - Street 1:900 FIELDSTONE TRL
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18040-7486
Practice Address - Country:US
Practice Address - Phone:570-620-6684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-18
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC013854101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPC013854OtherSTATE BOARD OF SOCIAL WORKERS, MARRIAGE & FAMILY THERAPISTS AND PROFESSIONAL COU