Provider Demographics
NPI:1114733987
Name:KING, NICOLE (PSYD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BROUWER LN
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-1702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 5TH AVE STE 2007
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6601
Practice Address - Country:US
Practice Address - Phone:212-506-5935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-06
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
026899103TB0200X
NY026899103TC0700X, 103TC2200X, 103TF0000X, 103TS0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool