Provider Demographics
NPI:1699363671
Name:SOUTRA, NICOLE ANNE (BACHELOR PYSCHOLOGY)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNE
Last Name:SOUTRA
Suffix:
Gender:F
Credentials:BACHELOR PYSCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 ATWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-4266
Mailing Address - Country:US
Mailing Address - Phone:413-582-0471
Mailing Address - Fax:413-585-9765
Practice Address - Street 1:8 ATWOOD DR
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-4266
Practice Address - Country:US
Practice Address - Phone:413-582-0471
Practice Address - Fax:413-585-9765
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor