Provider Demographics
NPI:1417284696
Name:NOGUEIRA, NICOLE WALLACE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:WALLACE
Last Name:NOGUEIRA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 MT AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138
Mailing Address - Country:US
Mailing Address - Phone:617-495-2042
Mailing Address - Fax:
Practice Address - Street 1:75 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4960
Practice Address - Country:US
Practice Address - Phone:617-495-2042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-10
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1154451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical