Provider Demographics
NPI:1285892372
Name:NICOLOFF, SHANNON MAUREEN (PSYD, LP, RPT)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MAUREEN
Last Name:NICOLOFF
Suffix:
Gender:F
Credentials:PSYD, LP, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 SUNNEHANNA DRIVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905
Mailing Address - Country:US
Mailing Address - Phone:651-894-2916
Mailing Address - Fax:
Practice Address - Street 1:323 BUDFIELD ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-3213
Practice Address - Country:US
Practice Address - Phone:651-894-2916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017512103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist