Healthcare Provider Details

I. General information

NPI: 1063836500
Provider Name (Legal Business Name): NICOLE PETZOLT PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2014
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 QUENTIN RD STE 110
BROOKLYN NY
11234-4245
US

IV. Provider business mailing address

3512 QUENTIN RD STE 110
BROOKLYN NY
11234-4245
US

V. Phone/Fax

Practice location:
  • Phone: 718-854-8370
  • Fax:
Mailing address:
  • Phone: 718-854-8370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number020428-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number020428-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number020428-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: