Healthcare Provider Details

I. General information

NPI: 1467357574
Provider Name (Legal Business Name): NICOL'S VILLAGE VIBES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 LATHAM VILLAGE LN APT 23
LATHAM NY
12110-3235
US

IV. Provider business mailing address

41 LATHAM VILLAGE LN APT 23
LATHAM NY
12110-3235
US

V. Phone/Fax

Practice location:
  • Phone: 518-852-7841
  • Fax: 518-245-0298
Mailing address:
  • Phone: 518-852-7841
  • Fax: 518-245-0298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: NICOL JENKINS
Title or Position: SOCIAL WORKER
Credential: LCSW-R
Phone: 518-852-7841