Provider Demographics
NPI:1316133606
Name:NICKERSON, LINDA RUTH (MA)
Entity type:Individual
Prefix:MS
First Name:LINDA
Middle Name:RUTH
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MRS
Other - First Name:LINDA
Other - Middle Name:NICKERSON
Other - Last Name:CONTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:147 DURHAM RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-2675
Mailing Address - Country:US
Mailing Address - Phone:203-464-3938
Mailing Address - Fax:203-245-0212
Practice Address - Street 1:147 DURHAM RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-2675
Practice Address - Country:US
Practice Address - Phone:203-464-3938
Practice Address - Fax:203-245-0212
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT070103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool