Provider Demographics
NPI:1932668118
Name:WEISE, NICOLA
Entity Type:Individual
Prefix:
First Name:NICOLA
Middle Name:
Last Name:WEISE
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 1:12 FREEMAN ST FL 2
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06114-2719
Mailing Address - Country:US
Mailing Address - Phone:860-922-7376
Mailing Address - Fax:
Practice Address - Street 1:3580 MAIN ST STE E
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06120-1121
Practice Address - Country:US
Practice Address - Phone:860-778-5317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical