Healthcare Provider Details

I. General information

NPI: 1427652478
Provider Name (Legal Business Name): NICOLE ZYGMONT M.ED., LBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE HERBERT

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 N EASTON RD
GLENSIDE PA
19038-4310
US

IV. Provider business mailing address

7002 W BUTLER PIKE FL 1
AMBLER PA
19002-5107
US

V. Phone/Fax

Practice location:
  • Phone: 844-966-0703
  • Fax:
Mailing address:
  • Phone: 215-285-3688
  • Fax: 844-966-0703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBH004857
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: