Basic Information
| Provider Information | |||||||||
| NPI: | 1487099495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POWELL-DANDY | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | DARCEL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MS,LADC1 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 DUDLEY ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021192769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179899623 | ||||||||
| FaxNumber: | 6174452672 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 DUDLEY ST | ||||||||
| Address2: | |||||||||
| City: | ROXBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021192769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179899623 | ||||||||
| FaxNumber: | 6174452672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2013 | ||||||||
| LastUpdateDate: | 05/03/2013 | ||||||||
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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 | 101YA0400X | 1884 | MA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.