Provider Demographics
NPI:1962855593
Name:ANTONIADIS, NICOLE ELIZABETH (PSYD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:ANTONIADIS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 POMEROY AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-7482
Mailing Address - Country:US
Mailing Address - Phone:203-694-5340
Mailing Address - Fax:203-694-5385
Practice Address - Street 1:61 POMEROY AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-7482
Practice Address - Country:US
Practice Address - Phone:203-694-5340
Practice Address - Fax:203-694-5385
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4290103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical