Provider Demographics
NPI:1629813043
Name:MARCIN, NIKKIA LEE
Entity type:Individual
Prefix:
First Name:NIKKIA
Middle Name:LEE
Last Name:MARCIN
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 1:593 E BROADWAY APT 3
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-4493
Mailing Address - Country:US
Mailing Address - Phone:617-388-2055
Mailing Address - Fax:
Practice Address - Street 1:593 E BROADWAY APT 3
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-4493
Practice Address - Country:US
Practice Address - Phone:617-388-2055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALMHC10001847261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health