Provider Demographics
NPI:1841805157
Name:LEWIS, NICOLE (LPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 ZANE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:NJ
Mailing Address - Zip Code:08029-1058
Mailing Address - Country:US
Mailing Address - Phone:570-460-3564
Mailing Address - Fax:
Practice Address - Street 1:2566 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-1743
Practice Address - Country:US
Practice Address - Phone:215-397-2943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009480101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional