Provider Demographics
NPI:1194481960
Name:FISHER, NICOLE PAULINA (MA, LAC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:PAULINA
Last Name:FISHER
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-2719
Mailing Address - Country:US
Mailing Address - Phone:609-714-8400
Mailing Address - Fax:
Practice Address - Street 1:66 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-2719
Practice Address - Country:US
Practice Address - Phone:609-714-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00611800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health