Provider Demographics
NPI:1720367329
Name:DESJARDINS, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DESJARDINS
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 1:585 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-1906
Mailing Address - Country:US
Mailing Address - Phone:508-831-0045
Mailing Address - Fax:508-853-1264
Practice Address - Street 1:585 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1906
Practice Address - Country:US
Practice Address - Phone:508-831-0045
Practice Address - Fax:508-853-1264
Is Sole Proprietor?:No
Enumeration Date:2011-08-12
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM18684OtherBLUE CROSS BLUE SHEILD
MA1308785Medicaid
MA1306461Medicaid
MA22220002001OtherBLUE CROSS
MA22220002001OtherBLUE CROSS