Provider Demographics
NPI:1871997403
Name:KRIES-WYSZYNSKI, NICOLE (MSW, LSW)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:KRIES-WYSZYNSKI
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 REGINA AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-2203
Mailing Address - Country:US
Mailing Address - Phone:732-674-7025
Mailing Address - Fax:
Practice Address - Street 1:129 REGINA AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-2203
Practice Address - Country:US
Practice Address - Phone:732-674-7025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-10
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL05838400101YA0400X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)