Provider Demographics
NPI:1679146633
Name:CONCEPCION, NICOLE ESTHER
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ESTHER
Last Name:CONCEPCION
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:ESTHER
Other - Last Name:CONCEPCION
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2905
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-5905
Mailing Address - Country:US
Mailing Address - Phone:787-410-2102
Mailing Address - Fax:
Practice Address - Street 1:URB VILLAS DEL ESTE
Practice Address - Street 2:CALLE AMBAR 998
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729
Practice Address - Country:US
Practice Address - Phone:787-410-2102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6987103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling