Healthcare Provider Details

I. General information

NPI: 1366791303
Provider Name (Legal Business Name): NICOLE HAWTHORNE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE HALLENBECK

II. Dates (important events)

Enumeration Date: 09/06/2012
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 MIDDLETOWN RD
WATERFORD NY
12188-1516
US

IV. Provider business mailing address

359 BALLSTON AVE
SARATOGA SPRINGS NY
12866-4723
US

V. Phone/Fax

Practice location:
  • Phone: 518-587-8008
  • Fax: 518-587-8241
Mailing address:
  • Phone: 518-587-8008
  • Fax: 518-587-8241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number001997
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: