Provider Demographics
NPI:1265295422
Name:NICOLIA, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:NICOLIA
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 1:30 BEAR PAW RD
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-1408
Mailing Address - Country:US
Mailing Address - Phone:203-984-5653
Mailing Address - Fax:
Practice Address - Street 1:2 CORPORATE DR STE 950
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6246
Practice Address - Country:US
Practice Address - Phone:203-293-0224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002581106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist