Provider Demographics
NPI:1336824846
Name:STEVENS, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:STEVENS
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 1:139 YARNES RD
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:PA
Mailing Address - Zip Code:18421-4020
Mailing Address - Country:US
Mailing Address - Phone:570-351-3024
Mailing Address - Fax:
Practice Address - Street 1:1300 OLD PLANK RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:PA
Practice Address - Zip Code:18433-1973
Practice Address - Country:US
Practice Address - Phone:570-281-6222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health