Provider Demographics
NPI:1336581511
Name:LONG, NICOLE (LICSW)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:LONG
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:PO BOX 456
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02303-0456
Mailing Address - Country:US
Mailing Address - Phone:508-251-9525
Mailing Address - Fax:
Practice Address - Street 1:150 WEST ST
Practice Address - Street 2:
Practice Address - City:WEST BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02379-1448
Practice Address - Country:US
Practice Address - Phone:508-251-9525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2013-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1171861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical