Healthcare Provider Details

I. General information

NPI: 1265206809
Provider Name (Legal Business Name): WILANDA NICOLAS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WALNUT AVE
CLARK NJ
07066-1253
US

IV. Provider business mailing address

100 WALNUT AVE
CLARK NJ
07066-1253
US

V. Phone/Fax

Practice location:
  • Phone: 917-722-1266
  • Fax:
Mailing address:
  • Phone: 917-722-1266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37PC01129600
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: