=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548000581
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE ELIZABETH DESHAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2024
-----------------------------------------------------
Last Update Date | 05/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 S MAIN ST
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08055-2455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-617-4544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 WISINA CT
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08055-9349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-556-3215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 37AC00793700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------