Provider Demographics
NPI:1417409053
Name:NICHOLS, STACY (LPC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:GUISTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:167 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-2637
Mailing Address - Country:US
Mailing Address - Phone:203-509-5510
Mailing Address - Fax:
Practice Address - Street 1:167 PARK AVE
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-2637
Practice Address - Country:US
Practice Address - Phone:203-509-5510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002999101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional