Basic Information
| Provider Information | |||||||||
| NPI: | 1033553003 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SESTITO | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 42 E LAUREL RD STE 1800 | ||||||||
| Address2: | |||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666843 | ||||||||
| FaxNumber: | 8565662775 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 E LAUREL RD STE 1800 | ||||||||
| Address2: | |||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666843 | ||||||||
| FaxNumber: | 8565662775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2013 | ||||||||
| LastUpdateDate: | 05/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103G00000X | PS017428 | PA | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103G00000X | 36384 | TX | N | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | 35SI00568600 | NJ | N | Behavioral Health & Social Service Providers | Psychologist | 103G00000X | 35SI00568600 | NJ | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist |
ID Information
| ID | Type | State | Issuer | Description | 0408883 | 05 | NJ | MEDICAID | 102906382 | 05 | PA | MEDICAID |