Healthcare Provider Details

I. General information

NPI: 1255463261
Provider Name (Legal Business Name): NICOLE JENNIFER YAGER MHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WAYNE BEHAVIORAL HEATLH NETWORK 1519 NYE ROAD
LYONS NY
14489
US

IV. Provider business mailing address

1692 RIDGE RD
ONTARIO NJ
14519
US

V. Phone/Fax

Practice location:
  • Phone: 315-946-5722
  • Fax: 315-946-7066
Mailing address:
  • Phone: 315-524-2686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberP54282
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: