Provider Demographics
NPI:1073376448
Name:DAVIS, NICKESHA SMALLHORNE
Entity Type:Individual
Prefix:
First Name:NICKESHA
Middle Name:SMALLHORNE
Last Name:DAVIS
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 1:57 MILLS ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-4941
Mailing Address - Country:US
Mailing Address - Phone:860-997-8414
Mailing Address - Fax:
Practice Address - Street 1:1 HARTFORD SQ STE 262
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1161
Practice Address - Country:US
Practice Address - Phone:203-444-3778
Practice Address - Fax:860-780-7080
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional