Provider Demographics
NPI:1962153692
Name:MOFFETT, NICOLE MARTHA (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARTHA
Last Name:MOFFETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARTHA
Other - Last Name:TWINING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:101 WASON AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1140
Mailing Address - Country:US
Mailing Address - Phone:413-426-5601
Mailing Address - Fax:
Practice Address - Street 1:101 WASON AVE FL 3
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1140
Practice Address - Country:US
Practice Address - Phone:413-426-5601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2248881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical