Healthcare Provider Details

I. General information

NPI: 1336788553
Provider Name (Legal Business Name): NICHOLAS EVERETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2020
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 LANCASTER AVE BLDG J
MALVERN PA
19355-1858
US

IV. Provider business mailing address

270 LANCASTER AVE BLDG J
MALVERN PA
19355-1858
US

V. Phone/Fax

Practice location:
  • Phone: 484-947-8820
  • Fax:
Mailing address:
  • Phone: 484-947-8820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC020163
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: