Provider Demographics
NPI:1194079103
Name:NICHOLS, STACEY J (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:J
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 W ORMOND AVE
Mailing Address - Street 2:STE 200-D
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-3054
Mailing Address - Country:US
Mailing Address - Phone:385-313-0680
Mailing Address - Fax:
Practice Address - Street 1:11 W ORMOND AVE
Practice Address - Street 2:STE 200-D
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-3054
Practice Address - Country:US
Practice Address - Phone:385-313-0680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8273583-3502101YM0800X
NJ44SC056566001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health