Provider Demographics
NPI:1982351896
Name:FILLISETTI, NICOLE M (CASAC-T)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:FILLISETTI
Suffix:
Gender:F
Credentials:CASAC-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 BLOOMINGDALE RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1604
Mailing Address - Country:US
Mailing Address - Phone:917-528-5612
Mailing Address - Fax:
Practice Address - Street 1:14 SLOSSON TER
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2507
Practice Address - Country:US
Practice Address - Phone:347-996-9321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)