Provider Demographics
NPI:1821780206
Name:MYKOLIW, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MYKOLIW
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 1:258 LEGENDS DR
Mailing Address - Street 2:
Mailing Address - City:DRUMS
Mailing Address - State:PA
Mailing Address - Zip Code:18222-3210
Mailing Address - Country:US
Mailing Address - Phone:732-318-7949
Mailing Address - Fax:
Practice Address - Street 1:5 PETHICK DR
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18702-6972
Practice Address - Country:US
Practice Address - Phone:570-300-9048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health