Provider Demographics
NPI:1366107153
Name:ESPINOZA, NICHOLAS A
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:ESPINOZA
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 1:837 MOUNTAIN TOP DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19426-4133
Mailing Address - Country:US
Mailing Address - Phone:561-635-6360
Mailing Address - Fax:
Practice Address - Street 1:1167 W. BALTIMORE PIKE #258
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5838
Practice Address - Country:US
Practice Address - Phone:484-577-9928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-05
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty