Provider Demographics
NPI:1558182352
Name:CAMPANELLO, NIKALAS
Entity type:Individual
Prefix:
First Name:NIKALAS
Middle Name:
Last Name:CAMPANELLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-4709
Mailing Address - Country:US
Mailing Address - Phone:860-395-7762
Mailing Address - Fax:
Practice Address - Street 1:71 RAYMOND RD
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2211
Practice Address - Country:US
Practice Address - Phone:203-232-4398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1888103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst