Healthcare Provider Details

I. General information

NPI: 1093596751
Provider Name (Legal Business Name): NICOLE PHILLIPS MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 FOLEY ST UNIT 1611
SOMERVILLE MA
02145-1314
US

IV. Provider business mailing address

485 FOLEY ST UNIT 1611
SOMERVILLE MA
02145-1314
US

V. Phone/Fax

Practice location:
  • Phone: 617-468-6939
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number229960
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLICSW1141431
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLICSW1141431
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLICSW1141431
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: