Healthcare Provider Details

I. General information

NPI: 1164557104
Provider Name (Legal Business Name): LAURA NICHOLS-VIRGILIO LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 DURHAM RD
PENNDEL PA
19047-5707
US

IV. Provider business mailing address

17 IROQUOIS RD
LEVITTOWN PA
19057-2307
US

V. Phone/Fax

Practice location:
  • Phone: 215-752-1541
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL05325200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: