Provider Demographics
NPI:1194155879
Name:MICHAUD, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MICHAUD
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 1:61 BRADLEY ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-5103
Mailing Address - Country:US
Mailing Address - Phone:860-516-1126
Mailing Address - Fax:
Practice Address - Street 1:61 BRADLEY ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5103
Practice Address - Country:US
Practice Address - Phone:860-516-1126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002846101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional