Healthcare Provider Details

I. General information

NPI: 1487371084
Provider Name (Legal Business Name): KRISTIN S NICELY COLANGELO LCSW, LCADC, CCS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 W MADISON AVE
COLLINGSWOOD NJ
08108-1426
US

IV. Provider business mailing address

13 W MADISON AVE
COLLINGSWOOD NJ
08108-1426
US

V. Phone/Fax

Practice location:
  • Phone: 609-405-7037
  • Fax:
Mailing address:
  • Phone: 609-405-7037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05652800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: