Provider Demographics
NPI:1003353616
Name:SANTOS, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SANTOS
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 1:591 MOORE ST
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-1607
Mailing Address - Country:US
Mailing Address - Phone:413-626-8084
Mailing Address - Fax:
Practice Address - Street 1:433 WEST ST
Practice Address - Street 2:SUITE 5
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002-2936
Practice Address - Country:US
Practice Address - Phone:413-687-3520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-21
Last Update Date:2017-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9947101YM0800X
CT2081101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health