Basic Information
| Provider Information | |||||||||
| NPI: | 1164905295 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICOLAIS | ||||||||
| FirstName: | CHRISTINA | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 SALINA MEADOWS PKWY | ||||||||
| Address2: | STE 100 | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132124516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154642000 | ||||||||
| FaxNumber: | 3154642010 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 EAST ADAMS ST | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154645450 | ||||||||
| FaxNumber: | 3154546322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2018 | ||||||||
| LastUpdateDate: | 10/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 023967 | NY | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 1473276 | 05 | OH | MEDICAID |