Provider Demographics
NPI:1366768418
Name:FORESTER, NICOLE TIPPETS
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:TIPPETS
Last Name:FORESTER
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 1:108 JERSEY ST
Mailing Address - Street 2:12A
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-4836
Mailing Address - Country:US
Mailing Address - Phone:801-557-9912
Mailing Address - Fax:
Practice Address - Street 1:6 PLEASANT ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5100
Practice Address - Country:US
Practice Address - Phone:781-322-1503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7063101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional