Provider Demographics
NPI:1457960601
Name:GIWA, NICOLE (LBA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GIWA
Suffix:
Gender:F
Credentials:LBA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:IMPERATO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LBA
Mailing Address - Street 1:158 LATHAM DR
Mailing Address - Street 2:
Mailing Address - City:GRISWOLD
Mailing Address - State:CT
Mailing Address - Zip Code:06351-3420
Mailing Address - Country:US
Mailing Address - Phone:203-671-0240
Mailing Address - Fax:
Practice Address - Street 1:95 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:CT
Practice Address - Zip Code:06424-1146
Practice Address - Country:US
Practice Address - Phone:860-604-6729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT123103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst