Healthcare Provider Details

I. General information

NPI: 1932668118
Provider Name (Legal Business Name): NICOLA WEISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 03/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3580 MAIN ST STE E
HARTFORD CT
06120-1121
US

IV. Provider business mailing address

12 FREEMAN ST FL 2
HARTFORD CT
06114-2719
US

V. Phone/Fax

Practice location:
  • Phone: 860-778-5317
  • Fax:
Mailing address:
  • Phone: 860-922-7376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: