Basic Information
| Provider Information | |||||||||
| NPI: | 1386123594 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | NICOLETTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 412503 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022412503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177263884 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15 OLD ROLLINSFORD RD STE 302 | ||||||||
| Address2: | |||||||||
| City: | DOVER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038202819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037429200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2018 | ||||||||
| LastUpdateDate: | 04/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 3133278 | 05 | NH | MEDICAID |