Provider Demographics
NPI:1073220885
Name:KILIC, NURSEN (LAC)
Entity type:Individual
Prefix:
First Name:NURSEN
Middle Name:
Last Name:KILIC
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 FLEETWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2014
Mailing Address - Country:US
Mailing Address - Phone:856-495-2411
Mailing Address - Fax:
Practice Address - Street 1:119 FLEETWOOD AVE
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-2014
Practice Address - Country:US
Practice Address - Phone:856-495-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00674700101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ37AC00674700OtherSTATE OF NEW JERSEY ATTORNEY GENERAL