Provider Demographics
NPI:1699084012
Name:WEAKLEY, NICHOLE M (MS)
Entity type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:M
Last Name:WEAKLEY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 WATERFALL DR
Mailing Address - Street 2:APT H
Mailing Address - City:CANTON
Mailing Address - State:MA
Mailing Address - Zip Code:02021-4162
Mailing Address - Country:US
Mailing Address - Phone:781-437-1323
Mailing Address - Fax:
Practice Address - Street 1:41 PACELLA PARK DR
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:MA
Practice Address - Zip Code:02368-1755
Practice Address - Country:US
Practice Address - Phone:781-437-1323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026265EMedicaid