=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619444007
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELL NICOLE WATERMAN M.ED.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2018
-----------------------------------------------------
Last Update Date | 10/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 95 FRANK B MURRAY ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01103-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-285-8586
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57 LOVE LN FL 3
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06112-1615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-778-4866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------