Provider Demographics
NPI:1235324567
Name:DEROBERTIS, NICOLE MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:DEROBERTIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 HAZEL TER
Mailing Address - Street 2:SUITE B
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-2209
Mailing Address - Country:US
Mailing Address - Phone:203-644-0557
Mailing Address - Fax:
Practice Address - Street 1:21 HAZEL TER
Practice Address - Street 2:SUITE B
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-2209
Practice Address - Country:US
Practice Address - Phone:203-644-0557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-10
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0078001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical