Provider Demographics
NPI:1619310794
Name:TAVERAS, NICOLE
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:TAVERAS
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 1:1266 FURNACE BROOK PKWY
Mailing Address - Street 2:SUITE 404
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4758
Mailing Address - Country:US
Mailing Address - Phone:617-481-9395
Mailing Address - Fax:888-434-5097
Practice Address - Street 1:1266 FURNACE BROOK PKWY
Practice Address - Street 2:SUITE 404
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4758
Practice Address - Country:US
Practice Address - Phone:617-481-9395
Practice Address - Fax:888-434-5097
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education