Provider Demographics
NPI:1427624725
Name:MCCOY, NICHOLAS JAMES (LMT)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JAMES
Last Name:MCCOY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:379 ROUTE 169
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:CT
Mailing Address - Zip Code:06281-3038
Mailing Address - Country:US
Mailing Address - Phone:860-341-6509
Mailing Address - Fax:
Practice Address - Street 1:74B SCHOOL ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-2132
Practice Address - Country:US
Practice Address - Phone:860-341-6509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT009893225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty