Provider Demographics
NPI:1740702547
Name:NIEVES, DOMINGO JR (CLINICAL COORDINATOR)
Entity type:Individual
Prefix:
First Name:DOMINGO
Middle Name:
Last Name:NIEVES
Suffix:JR
Gender:M
Credentials:CLINICAL COORDINATOR
Other - Prefix:
Other - First Name:DOMINGO
Other - Middle Name:
Other - Last Name:NIEVES
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:CLINICAL COORDINATOR
Mailing Address - Street 1:2257 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1905
Mailing Address - Country:US
Mailing Address - Phone:413-733-3488
Mailing Address - Fax:413-731-7381
Practice Address - Street 1:2225 MAIN ST.
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107
Practice Address - Country:US
Practice Address - Phone:413-733-3488
Practice Address - Fax:413-731-7381
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3080010Medicaid
MA1301829Medicaid