MEDICARE: WILANDA NICOLAS LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor
2	101YM0800X	Mental Health Counselor	37PC01129600	NJ
3	101YP1600X	Pastoral Counselor

General Provider Information

NPI Number	:	1265206809
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILANDA NICOLAS LPC

Provider Business Mailing Address
First Line	:	100 WALNUT AVE
Second Line	:
City	:	CLARK
State	:	NJ
Zip	:	07066-1253
Country	:	US
Telephone Number	:	917-722-1266
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 WALNUT AVE
Second Line	:
City	:	CLARK
State	:	NJ
Zip	:	07066-1253
Country	:	US
Telephone Number	:	917-722-1266
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2023
Last Update Date	:	04/14/2026

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Directions to “ WILANDA NICOLAS LPC” Practice Location

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