Provider Demographics
NPI:1972676054
Name:NIETO, ALICE G (LICSW)
Entity Type:Individual
Prefix:MS
First Name:ALICE
Middle Name:G
Last Name:NIETO
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 KELSEY ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-4337
Mailing Address - Country:US
Mailing Address - Phone:860-956-7924
Mailing Address - Fax:
Practice Address - Street 1:509 WETHERSFIELD AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06114-1907
Practice Address - Country:US
Practice Address - Phone:860-296-2121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004779261QM0850X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical