Provider Demographics
NPI:1376043471
Name:NICHOLSON, THERESA (LADC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 PROSPECT AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-4245
Mailing Address - Country:US
Mailing Address - Phone:860-337-7178
Mailing Address - Fax:203-439-2087
Practice Address - Street 1:660 PROSPECT AVE 3RD FL
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-4245
Practice Address - Country:US
Practice Address - Phone:860-337-7178
Practice Address - Fax:203-439-2087
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000235101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT815373713Medicaid