Provider Demographics
NPI:1912416389
Name:DOUGLAS, NICOLE (LPC ACS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:LPC ACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 S MAPLE AVE APT 310
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2217
Mailing Address - Country:US
Mailing Address - Phone:732-379-7398
Mailing Address - Fax:
Practice Address - Street 1:60 W LANDIS AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-8107
Practice Address - Country:US
Practice Address - Phone:856-772-5809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-28
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00380400101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ37AC00380400Medicaid