Healthcare Provider Details

I. General information

NPI: 1871130138
Provider Name (Legal Business Name): NICOLE SHEA PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2019
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 MAIN ST FL 4
BUFFALO NY
14203-1009
US

IV. Provider business mailing address

1001 MAIN ST FL 5
BUFFALO NY
14203-1009
US

V. Phone/Fax

Practice location:
  • Phone: 716-323-0110
  • Fax:
Mailing address:
  • Phone: 716-323-0110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number023460
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: