Provider Demographics
NPI:1003230624
Name:BURNS, NICHOLE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:BURNS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MONTAUK AVENE
Mailing Address - Street 2:P.O. BOX 390
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-6344
Mailing Address - Country:US
Mailing Address - Phone:860-271-4715
Mailing Address - Fax:860-271-4797
Practice Address - Street 1:21 MONTAUK AVENE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4906
Practice Address - Country:US
Practice Address - Phone:860-271-4715
Practice Address - Fax:860-271-4797
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008059339Medicaid
CTD400229188Medicare PIN