Provider Demographics
NPI:1891192852
Name:NIKELSHPUR, OLGA MAGIDINA (PHD,)
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:MAGIDINA
Last Name:NIKELSHPUR
Suffix:
Gender:F
Credentials:PHD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 ESSEX ST STE 303
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-8566
Mailing Address - Country:US
Mailing Address - Phone:917-769-6557
Mailing Address - Fax:
Practice Address - Street 1:360 ESSEX ST STE 303
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-8566
Practice Address - Country:US
Practice Address - Phone:917-769-6557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020815 -1103T00000X
NJ35SI00622100103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist