Provider Demographics
NPI:1922503200
Name:MATERO, NICOLE E (LSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:E
Last Name:MATERO
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17101-1211
Mailing Address - Country:US
Mailing Address - Phone:717-891-1291
Mailing Address - Fax:
Practice Address - Street 1:513 W CHOCOLATE AVE STE 100
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-1632
Practice Address - Country:US
Practice Address - Phone:717-810-1974
Practice Address - Fax:717-704-8476
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA128886104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1992219588Medicaid