MEDICARE: NICOLLETTE ROSE AIRHART LCSW

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	1041C0700X	Clinical Social Worker	CW019852	PA

General Provider Information

NPI Number	:	1508369141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLLETTE ROSE AIRHART LCSW

Provider Business Mailing Address
First Line	:	2686 TILTON ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19125-4017
Country	:	US
Telephone Number	:	330-495-8763
Fax Number	:

Provider Business Practice Location Address
First Line	:	1819 JOHN F KENNEDY BLVD STE 302
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-1729
Country	:	US
Telephone Number	:	330-495-8763
Fax Number	:

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

Provider Enumeration Date	:	03/09/2018
Last Update Date	:	03/09/2018

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