Provider Demographics
NPI:1427153493
Name:STEVENS, NICOLE ELICIA (LICSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELICIA
Last Name:STEVENS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 SUMNER AVE
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01062-1426
Mailing Address - Country:US
Mailing Address - Phone:413-587-0401
Mailing Address - Fax:
Practice Address - Street 1:200 MAIN ST
Practice Address - Street 2:SUITE 2A
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3170
Practice Address - Country:US
Practice Address - Phone:413-320-1108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1115881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO8397OtherBLUE CROSS BLUE SHIELD
MA240242OtherTRICARE
MAPO8397OtherBLUE CROSS BLUE SHIELD