Provider Demographics
NPI:1063899748
Name:BOSTON, NICOLE (LPC, MA, MHS)
Entity type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:
Last Name:BOSTON
Suffix:
Gender:F
Credentials:LPC, MA, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 PEARTREE LN
Mailing Address - Street 2:
Mailing Address - City:WILLINGBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08046-2709
Mailing Address - Country:US
Mailing Address - Phone:267-456-4765
Mailing Address - Fax:
Practice Address - Street 1:31 PEARTREE LN
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-2709
Practice Address - Country:US
Practice Address - Phone:267-456-4765
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-01
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC008130101YP2500X
NJ37PC00551500101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional