MEDICARE: NICHOLE CHRISTINA LABOLLITA CADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	37CA00156200	NJ

General Provider Information

NPI Number	:	1295391886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLE CHRISTINA LABOLLITA CADC

Provider Business Mailing Address
First Line	:	245 ATLANTIC CITY BLVD
Second Line	:
City	:	BEACHWOOD
State	:	NJ
Zip	:	08722-2972
Country	:	US
Telephone Number	:	732-232-2034
Fax Number	:

Provider Business Practice Location Address
First Line	:	245 ATLANTIC CITY BLVD
Second Line	:
City	:	BEACHWOOD
State	:	NJ
Zip	:	08722-2972
Country	:	US
Telephone Number	:	732-232-2034
Fax Number	:

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

Provider Enumeration Date	:	05/20/2019
Last Update Date	:	05/20/2019

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