Provider Demographics
NPI:1184401200
Name:JOSEPH, NICHOLAS (PHD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 CORPORATE WAY STE 2M
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-2027
Mailing Address - Country:US
Mailing Address - Phone:718-362-1411
Mailing Address - Fax:718-414-1651
Practice Address - Street 1:1520 S GRANT ST
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-6538
Practice Address - Country:US
Practice Address - Phone:718-362-1411
Practice Address - Fax:718-414-1651
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11985103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical