Healthcare Provider Details

I. General information

NPI: 1750549853
Provider Name (Legal Business Name): RENESHA LINNETTE NICHOLS MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2008
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WOODLAND ST
HARTFORD CT
06105-1233
US

IV. Provider business mailing address

43 DARBY ST
BLOOMFIELD CT
06002-3607
US

V. Phone/Fax

Practice location:
  • Phone: 860-241-0317
  • Fax: 860-241-0327
Mailing address:
  • Phone: 860-243-9694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number187695384
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: