Provider Demographics
NPI:1457105132
Name:STORER, NICOLE M (CPRS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:STORER
Suffix:
Gender:F
Credentials:CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 BANNARD ST
Mailing Address - Street 2:
Mailing Address - City:CINNAMINSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08077-1902
Mailing Address - Country:US
Mailing Address - Phone:609-310-8189
Mailing Address - Fax:
Practice Address - Street 1:610 PEMBERTON BROWNS MILLS RD
Practice Address - Street 2:
Practice Address - City:PEMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08068-1537
Practice Address - Country:US
Practice Address - Phone:856-271-4486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1000140324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility