Provider Demographics
NPI:1548572126
Name:STAITI, NICOLE M (BA)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:M
Last Name:STAITI
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:BARRE
Mailing Address - State:MA
Mailing Address - Zip Code:01005-8909
Mailing Address - Country:US
Mailing Address - Phone:978-355-4541
Mailing Address - Fax:
Practice Address - Street 1:455 SOUTH ST
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:MA
Practice Address - Zip Code:01005-8909
Practice Address - Country:US
Practice Address - Phone:978-355-4541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-12
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1475136322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children