Provider Demographics
NPI:1548702509
Name:LEWIS, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 EAST CENTER STREET
Mailing Address - Street 2:SUITE 2A WEST
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040
Mailing Address - Country:US
Mailing Address - Phone:860-385-2027
Mailing Address - Fax:
Practice Address - Street 1:63 EAST CENTER STREET
Practice Address - Street 2:SUIT 2A WEST
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040
Practice Address - Country:US
Practice Address - Phone:860-385-2027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-08
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CT003568101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA042174657Medicaid