Basic Information
Provider Information | |||||||||
NPI: | 1134426406 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DRURY | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 147 NORMAN ST | ||||||||
Address2: |   | ||||||||
City: | WEST SPRINGFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 010895003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137368329 | ||||||||
FaxNumber: | 4137325362 | ||||||||
Practice Location | |||||||||
Address1: | 25 MOORELAND ST | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 011041826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137855851 | ||||||||
FaxNumber: | 4137855854 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2011 | ||||||||
LastUpdateDate: | 02/22/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor |   |
ID Information
ID | Type | State | Issuer | Description | 1303295 (MH) | 05 | MA |   | MEDICAID | M18463 | 01 |   | BC / BS | OTHER | 1307756 | 05 | MA |   | MEDICAID |