Provider Demographics
NPI:1215481965
Name:YOUNGWIRTH, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:YOUNGWIRTH
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 1:77 INMAN ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-1212
Mailing Address - Country:US
Mailing Address - Phone:781-424-0475
Mailing Address - Fax:
Practice Address - Street 1:77 INMAN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-1212
Practice Address - Country:US
Practice Address - Phone:781-424-0475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-11
Last Update Date:2021-04-20
Deactivation Date:2019-05-08
Deactivation Code:
Reactivation Date:2021-04-20
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor