Provider Demographics
NPI:1457549578
Name:NICKERSON COMMUNITY CENTER
Entity type:Organization
Organization Name:NICKERSON COMMUNITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:D'AMBRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-351-2241
Mailing Address - Street 1:133 DELAINE ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-2728
Mailing Address - Country:US
Mailing Address - Phone:401-351-2241
Mailing Address - Fax:
Practice Address - Street 1:97 DELAINE ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-2726
Practice Address - Country:US
Practice Address - Phone:401-383-5672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No251S00000XAgenciesCommunity/Behavioral Health