1700921038 NPI number — DR. KATHARINE MARIE NICODEMUS PSYD

Table of content: DR. KATHARINE MARIE NICODEMUS PSYD (NPI 1700921038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700921038 NPI number — DR. KATHARINE MARIE NICODEMUS PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICODEMUS
Provider First Name:
KATHARINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700921038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4011 SPRINGFIELD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19807-2251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-645-1300
Provider Business Mailing Address Fax Number:
302-645-1317

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16529 COASTAL HWY
Provider Second Line Business Practice Location Address:
SUITE 113
Provider Business Practice Location Address City Name:
LEWES
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19958-3605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-645-1300
Provider Business Practice Location Address Fax Number:
302-645-1317
Provider Enumeration Date:
02/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  BL-0000656 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103TC0700X , with the licence number: BL-0000656 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)





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