Provider Demographics
NPI:1245019702
Name:NICHOLSON, LAURIE
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:NICHOLSON
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 1:2253 24TH ST APT 1
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-3412
Mailing Address - Country:US
Mailing Address - Phone:347-624-4425
Mailing Address - Fax:
Practice Address - Street 1:2253 24TH ST APT 1
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-3412
Practice Address - Country:US
Practice Address - Phone:347-624-4425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician