Provider Demographics
NPI:1942049887
Name:VENTURA ROACH, NICOLE (MA, LPC, RDT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:VENTURA ROACH
Suffix:
Gender:F
Credentials:MA, LPC, RDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-5210
Mailing Address - Country:US
Mailing Address - Phone:201-669-0057
Mailing Address - Fax:
Practice Address - Street 1:85 WILLOW ST STE 7
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-2696
Practice Address - Country:US
Practice Address - Phone:203-871-1876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
834101200000X
CT6384101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101200000XBehavioral Health & Social Service ProvidersDrama Therapist