Provider Demographics
NPI:1376664722
Name:NICOLL, MARY KATHRYN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY KATHRYN
Middle Name:
Last Name:NICOLL
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 1:315 N BROOKSVALE RD
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3336
Mailing Address - Country:US
Mailing Address - Phone:203-272-8486
Mailing Address - Fax:
Practice Address - Street 1:300 CHURCH ST STE 105
Practice Address - Street 2:
Practice Address - City:YALESVILLE
Practice Address - State:CT
Practice Address - Zip Code:06492-2253
Practice Address - Country:US
Practice Address - Phone:203-679-0849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0026171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004237352Medicaid