Healthcare Provider Details

I. General information

NPI: 1982110227
Provider Name (Legal Business Name): NICOLAS SHERIDAN MA, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2017
Last Update Date: 04/04/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 ATWATER DR STE 130
MALVERN PA
19355-8782
US

IV. Provider business mailing address

1200 ATWATER DR STE 130
MALVERN PA
19355-8782
US

V. Phone/Fax

Practice location:
  • Phone: 610-646-1851
  • Fax: 484-355-5181
Mailing address:
  • Phone: 610-646-1851
  • Fax: 484-355-5181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC016042
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: