Provider Demographics
NPI:1174194575
Name:CALDERON, NICOLE LUZMILA (LCAT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LUZMILA
Last Name:CALDERON
Suffix:
Gender:F
Credentials:LCAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22240 EDMORE AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1918
Mailing Address - Country:US
Mailing Address - Phone:347-451-4769
Mailing Address - Fax:
Practice Address - Street 1:9114 MERRICK BLVD STE 3
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5363
Practice Address - Country:US
Practice Address - Phone:347-451-4769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-07
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101Y00000X
NY002968221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor