Provider Demographics
NPI:1750568176
Name:MAXIMIN-JOSEPH, NICOLE M (CASAC)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:M
Last Name:MAXIMIN-JOSEPH
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 WILLIAM FLOYD PKWY
Mailing Address - Street 2:
Mailing Address - City:EAST YAPHANK
Mailing Address - State:NY
Mailing Address - Zip Code:11967-1820
Mailing Address - Country:US
Mailing Address - Phone:631-924-3741
Mailing Address - Fax:631-924-2413
Practice Address - Street 1:1490 WILLIAM FLOYD PKWY
Practice Address - Street 2:
Practice Address - City:EAST YAPHANK
Practice Address - State:NY
Practice Address - Zip Code:11967-1820
Practice Address - Country:US
Practice Address - Phone:631-924-3741
Practice Address - Fax:631-924-2413
Is Sole Proprietor?:No
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY13080101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY13080Medicaid
NY13080Medicare UPIN
NY13080Medicaid