=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144995390
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NICOLE COLLINS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2021
-----------------------------------------------------
Last Update Date | 08/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64 IROQUOIS RD APT 1
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06902-8706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-205-1021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 64 IROQUOIS RD APT 1
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06902-8706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 475-205-1021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NICOLE COLLINS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 475-205-1021
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------