MEDICARE: DR. SHANNON MAUREEN NICOLOFF PSY.D., L.P., RPT

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	103T00000X	Psychologist	PS017512	PA

General Provider Information

NPI Number	:	1285892372
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON MAUREEN NICOLOFF PSY.D., L.P., RPT

Provider Business Mailing Address
First Line	:	807 SUNNEHANNA DRIVE
Second Line	:
City	:	JOHNSTOWN
State	:	PA
Zip	:	15905
Country	:	US
Telephone Number	:	651-894-2916
Fax Number	:

Provider Business Practice Location Address
First Line	:	323 BUDFIELD ST
Second Line	:
City	:	JOHNSTOWN
State	:	PA
Zip	:	15904-3213
Country	:	US
Telephone Number	:	651-894-2916
Fax Number	:

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

Provider Enumeration Date	:	05/27/2008
Last Update Date	:	06/18/2014

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