Provider Demographics
NPI:1659858520
Name:MATZOURANIS, NIKOLE ELAINE (LICSW)
Entity Type:Individual
Prefix:
First Name:NIKOLE
Middle Name:ELAINE
Last Name:MATZOURANIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 EAST ST
Mailing Address - Street 2:
Mailing Address - City:METHUEN
Mailing Address - State:MA
Mailing Address - Zip Code:01844-4597
Mailing Address - Country:US
Mailing Address - Phone:978-687-0156
Mailing Address - Fax:978-659-6004
Practice Address - Street 1:70 EAST ST
Practice Address - Street 2:
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844-4597
Practice Address - Country:US
Practice Address - Phone:978-687-0156
Practice Address - Fax:978-659-6004
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1117131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110087057AMedicaid