Healthcare Provider Details

I. General information

NPI: 1639971807
Provider Name (Legal Business Name): NICOLE DUNBAR BRUSH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 DUNBAR DR
OLD FORGE PA
18518-2008
US

IV. Provider business mailing address

220 DUNBAR DR
OLD FORGE PA
18518-2008
US

V. Phone/Fax

Practice location:
  • Phone: 570-313-6098
  • Fax:
Mailing address:
  • Phone: 570-313-6098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: NICOLE DUNBAR BRUSH
Title or Position: LICENSED PROFESSIONAL COUNSELOR
Credential:
Phone: 570-313-6098