Provider Demographics
NPI:1215220926
Name:MARESCA, NICOLE L (MS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:MARESCA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LYNMARIE
Other - Last Name:CORMIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:390 RIVER STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156
Mailing Address - Country:US
Mailing Address - Phone:802-886-4500
Mailing Address - Fax:802-886-4560
Practice Address - Street 1:49 SCHOOL STREET
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:VT
Practice Address - Zip Code:05047
Practice Address - Country:US
Practice Address - Phone:802-295-3031
Practice Address - Fax:802-295-0820
Is Sole Proprietor?:No
Enumeration Date:2011-05-27
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
VT068.0132204101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RE2534Medicare PIN