Provider Demographics
NPI:1396719712
Name:CROTEAU-JOHNSON, NICOLE (LPA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CROTEAU-JOHNSON
Suffix:
Gender:F
Credentials:LPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-4021
Mailing Address - Country:US
Mailing Address - Phone:910-251-0300
Mailing Address - Fax:910-251-0310
Practice Address - Street 1:411 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-4021
Practice Address - Country:US
Practice Address - Phone:910-251-0300
Practice Address - Fax:910-251-0310
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2375103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC13575OtherBLUE CROSS BLUE SHIELD
NC6107038Medicaid