Provider Demographics
NPI:1770887853
Name:DERICKS, NICOLE MARIE (MED, LPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:DERICKS
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1881 BRODHEAD RD
Mailing Address - Street 2:
Mailing Address - City:ALIQUIPPA
Mailing Address - State:PA
Mailing Address - Zip Code:15001-5074
Mailing Address - Country:US
Mailing Address - Phone:412-523-3834
Mailing Address - Fax:
Practice Address - Street 1:117 VIP DR
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-6932
Practice Address - Country:US
Practice Address - Phone:724-934-3905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC006396101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional