Provider Demographics
NPI:1528410057
Name:WARGO-BOSWELL, NICOLLE
Entity Type:Individual
Prefix:
First Name:NICOLLE
Middle Name:
Last Name:WARGO-BOSWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MANSE HILL RD
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:CT
Mailing Address - Zip Code:06071-1544
Mailing Address - Country:US
Mailing Address - Phone:860-245-8955
Mailing Address - Fax:860-541-5389
Practice Address - Street 1:624 TALCOTTVILLE RD STE 2
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-2390
Practice Address - Country:US
Practice Address - Phone:860-245-8955
Practice Address - Fax:860-541-5389
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health