Provider Demographics
NPI:1467888438
Name:NICOLE LONG
Entity Type:Organization
Organization Name:NICOLE LONG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-927-2464
Mailing Address - Street 1:PO BOX 456
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02303-0456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 WEST ST
Practice Address - Street 2:
Practice Address - City:WEST BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02379-1448
Practice Address - Country:US
Practice Address - Phone:508-927-2464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-22
Last Update Date:2013-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1171861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty