Provider Demographics
NPI:1346788676
Name:DESIMONE, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DESIMONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 CHEWS LANDING RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL SPRINGS
Mailing Address - State:NJ
Mailing Address - Zip Code:08021
Mailing Address - Country:US
Mailing Address - Phone:856-258-7575
Mailing Address - Fax:
Practice Address - Street 1:1395 CHEWS LANDING RD
Practice Address - Street 2:
Practice Address - City:LAUREL SPRINGS
Practice Address - State:NJ
Practice Address - Zip Code:08021
Practice Address - Country:US
Practice Address - Phone:856-258-7575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-07
Last Update Date:2021-07-16
Deactivation Date:2018-08-21
Deactivation Code:
Reactivation Date:2018-10-03
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00251500101YA0400X, 101YM0800X
NJ37PC00776800101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health