MEDICARE: MS. ELLEN S NICOL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	221700000X	Art Therapist	3	CT

General Provider Information

NPI Number	:	1487273876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELLEN S NICOL

Provider Business Mailing Address
First Line	:	57 NORTH ST STE 419
Second Line	:
City	:	DANBURY
State	:	CT
Zip	:	06810-5629
Country	:	US
Telephone Number	:	203-778-3838
Fax Number	:	203-778-4040

Provider Business Practice Location Address
First Line	:	57 NORTH ST STE 419
Second Line	:
City	:	DANBURY
State	:	CT
Zip	:	06810-5629
Country	:	US
Telephone Number	:	203-778-3838
Fax Number	:	203-778-4040

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2020
Last Update Date	:	04/15/2020

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