Healthcare Provider Details

I. General information

NPI: 1831843010
Provider Name (Legal Business Name): NICOLE G DERISI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2022
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date: 05/27/2026
Reactivation Date: 07/02/2026

III. Provider practice location address

2035 LINCOLN HWY STE 1150
EDISON NJ
08817-3351
US

IV. Provider business mailing address

293 COLONIA BLVD
COLONIA NJ
07067-3025
US

V. Phone/Fax

Practice location:
  • Phone: 866-557-8669
  • Fax:
Mailing address:
  • Phone: 732-675-1868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberRBT-21-198035
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: