Provider Demographics
NPI:1245053479
Name:NICOLAS, JOHN KELLY (MHC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:KELLY
Last Name:NICOLAS
Suffix:
Gender:M
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 OLD SOUTH PLANK RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-1528
Mailing Address - Country:US
Mailing Address - Phone:347-681-7164
Mailing Address - Fax:
Practice Address - Street 1:13 OLD SOUTH PLANK RD
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-1528
Practice Address - Country:US
Practice Address - Phone:347-681-7164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-05
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18-P131615-01101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health