Provider Demographics
NPI:1831843010
Name:DERISI, NICOLE G
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:G
Last Name:DERISI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 COLONIA BLVD
Mailing Address - Street 2:
Mailing Address - City:COLONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07067-3025
Mailing Address - Country:US
Mailing Address - Phone:732-675-1868
Mailing Address - Fax:
Practice Address - Street 1:2035 LINCOLN HWY STE 1150
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-3351
Practice Address - Country:US
Practice Address - Phone:866-557-8669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRBT-21-198035106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician