Healthcare Provider Details

I. General information

NPI: 1538095013
Provider Name (Legal Business Name): NICOY DOUGLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 HEBERLE RD
ROCHESTER NY
14609-1702
US

IV. Provider business mailing address

67 HEBERLE RD
ROCHESTER NY
14609-1702
US

V. Phone/Fax

Practice location:
  • Phone: 585-285-8703
  • Fax:
Mailing address:
  • Phone: 585-285-8703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: