Healthcare Provider Details

I. General information

NPI: 1457549578
Provider Name (Legal Business Name): NICKERSON COMMUNITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97 DELAINE ST
PROVIDENCE RI
02909-2726
US

IV. Provider business mailing address

133 DELAINE ST
PROVIDENCE RI
02909-2728
US

V. Phone/Fax

Practice location:
  • Phone: 401-383-5672
  • Fax:
Mailing address:
  • Phone: 401-351-2241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: LISA D'AMBRA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 401-351-2241