Provider Demographics
NPI:1962795922
Name:JOHNSON, NICOLE GABBRIELLE (PHD, LPC, CAADC)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:GABBRIELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD, LPC, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7550 RUGBY ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-2608
Mailing Address - Country:US
Mailing Address - Phone:215-313-1743
Mailing Address - Fax:
Practice Address - Street 1:7550 RUGBY ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19150-2608
Practice Address - Country:US
Practice Address - Phone:215-313-1743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA5651101YA0400X
PA7378101YA0400X
PAPC005270101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)