Provider Demographics
NPI:1699289199
Name:NICKERSON, SARAH MARIE
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:MARIE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:MARIE
Other - Last Name:COSTELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:560 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-3119
Mailing Address - Country:US
Mailing Address - Phone:207-614-2313
Mailing Address - Fax:646-859-4440
Practice Address - Street 1:560 SYLVAN AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-3119
Practice Address - Country:US
Practice Address - Phone:646-873-6660
Practice Address - Fax:646-859-4440
Is Sole Proprietor?:No
Enumeration Date:2017-11-21
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MA1-19-38049103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician