Basic Information
| Provider Information | |||||||||
| NPI: | 1235525387 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESPOELBERCH | ||||||||
| FirstName: | NICHOLAS | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 HAZEL TERRACE | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038197650 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 30 HAZEL TERRACE | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038197650 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2015 | ||||||||
| LastUpdateDate: | 03/31/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 2729 | CT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 008058532 | 01 | CT | DESPOELBERCH MEDICAID | OTHER |