MEDICARE: STACEY NICHOLAS LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YP2500X	Professional Counselor
2	106H00000X	Marriage & Family Therapist
3	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1376843615
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STACEY NICHOLAS LLC

Provider Business Mailing Address
First Line	:	285 E MAIN ST
Second Line	:
City	:	SOMERVILLE
State	:	NJ
Zip	:	08876-3005
Country	:	US
Telephone Number	:	908-707-0212
Fax Number	:

Provider Business Practice Location Address
First Line	:	285 E MAIN ST
Second Line	:
City	:	SOMERVILLE
State	:	NJ
Zip	:	08876-3005
Country	:	US
Telephone Number	:	908-707-0212
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	STACEY NICHOLAS
Credential	:	LCSW
Telephone Number	:	908-707-0212

Provider Enumeration Date	:	11/02/2010
Last Update Date	:	08/02/2021

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Directions to “STACEY NICHOLAS LLC ” Practice Location

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