Healthcare Provider Details

I. General information

NPI: 1609398445
Provider Name (Legal Business Name): NIKELE RIEK LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 07/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 BAINBRIDGE STREET
PHILADELPHIA PA
19147
US

IV. Provider business mailing address

5455 CEDAR AVE
PHILADELPHIA PA
19143-1953
US

V. Phone/Fax

Practice location:
  • Phone: 215-563-0652
  • Fax: 215-563-0664
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW132656
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: