Provider Demographics
NPI:1154458438
Name:ISSA, NICOLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:ISSA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 S ANGELL ST # 405
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5206
Mailing Address - Country:US
Mailing Address - Phone:401-330-5882
Mailing Address - Fax:401-663-6628
Practice Address - Street 1:382 THAYER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-1558
Practice Address - Country:US
Practice Address - Phone:401-330-5882
Practice Address - Fax:401-226-0137
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9797103TC0700X
NY021654103TC0700X
RIPS01615103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical