Healthcare Provider Details

I. General information

NPI: 1033432034
Provider Name (Legal Business Name): MATTHEW ROBERT NICOLI LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2010
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 VANDENBERG DR 66 MDS (AFMC)
HANSCOM AFB MA
01731-2104
US

IV. Provider business mailing address

90 VANDENBERG DR 66 MDS (AFMC)
HANSCOM AFB MA
01731-2104
US

V. Phone/Fax

Practice location:
  • Phone: 781-225-6789
  • Fax: 781-225-2576
Mailing address:
  • Phone: 781-225-6789
  • Fax: 781-225-2576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number115181
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: