Provider Demographics
NPI:1932312006
Name:LIVELY, NICOLE
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:LIVELY
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 1:7400 YORK RD
Mailing Address - Street 2:SUITE #303
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21204-7531
Mailing Address - Country:US
Mailing Address - Phone:410-828-6656
Mailing Address - Fax:
Practice Address - Street 1:7400 YORK RD
Practice Address - Street 2:SUITE #303
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21204-7531
Practice Address - Country:US
Practice Address - Phone:410-828-6656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDW10821023101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health