Provider Demographics
NPI:1740204890
Name:NICHOLAS, MARY W (PHD, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:W
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WATER ST
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2861
Mailing Address - Country:US
Mailing Address - Phone:203-458-0661
Mailing Address - Fax:203-458-6068
Practice Address - Street 1:441 ORANGE ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6217
Practice Address - Country:US
Practice Address - Phone:203-776-4495
Practice Address - Fax:203-458-6068
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0013361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical