Basic Information
| Provider Information | |||||||||
| NPI: | 1124770763 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLSON | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | KATHLEEN | ||||||||
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| Credential: | M.ED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 OTIS ST | ||||||||
| Address2: | |||||||||
| City: | MANSFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020482057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088519058 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30 TAUNTON GRN STE 5 | ||||||||
| Address2: | |||||||||
| City: | TAUNTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027803243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088806666 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2022 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YS0200X | 446427 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | School |
No ID Information.