Healthcare Provider Details

I. General information

NPI: 1497646921
Provider Name (Legal Business Name): NICHOL VICTORIA CLARK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2025
Last Update Date: 07/12/2025
Certification Date: 07/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DEERFIELD LN
MALVERN PA
19355-2146
US

IV. Provider business mailing address

2025 ROY AVE
ABINGTON PA
19001-1812
US

V. Phone/Fax

Practice location:
  • Phone: 610-933-8110
  • Fax:
Mailing address:
  • Phone: 215-917-8229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: