Basic Information
| Provider Information | |||||||||
| NPI: | 1437499100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOUDREAU-GREEN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18 MILLER RD | ||||||||
| Address2: | |||||||||
| City: | MAHOPAC | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105412220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9148254800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 845 NORTH BROADWAY | ||||||||
| Address2: | |||||||||
| City: | N WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142312590 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2013 | ||||||||
| LastUpdateDate: | 12/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 083258 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 007893 | CT | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.