Provider Demographics
NPI:1982906715
Name:NICHOLSON, BRENNA MARIE (LPC)
Entity type:Individual
Prefix:MRS
First Name:BRENNA
Middle Name:MARIE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MISS
Other - First Name:BRENNA
Other - Middle Name:MARIE
Other - Last Name:DOBOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:408 HIGHLAND AVE
Mailing Address - Street 2:BLDG A, SUITE 6
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-2525
Mailing Address - Country:US
Mailing Address - Phone:203-494-9030
Mailing Address - Fax:
Practice Address - Street 1:408 HIGHLAND AVE
Practice Address - Street 2:BLDG A, SUITE 6
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-2525
Practice Address - Country:US
Practice Address - Phone:203-494-9030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001919101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health