Provider Demographics
NPI:1063151090
Name:THOMAS, NICOLE M (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:THOMAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 MAINBRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:WILLINGBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08046-2101
Mailing Address - Country:US
Mailing Address - Phone:718-644-0854
Mailing Address - Fax:
Practice Address - Street 1:975 ROUTE 73 N STE A
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-1281
Practice Address - Country:US
Practice Address - Phone:718-644-0854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-28
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC06125900104100000X
DEQ30000079104100000X
DEQ10012082104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker