Basic Information
Provider Information | |||||||||
NPI: | 1730253501 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NARDIZZI | ||||||||
FirstName: | NICOLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 20 BRIDGE STREET | ||||||||
Address2: |   | ||||||||
City: | GREENWICH | ||||||||
State: | CT | ||||||||
PostalCode: | 06830 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2036292822 | ||||||||
FaxNumber: | 2036292940 | ||||||||
Practice Location | |||||||||
Address1: | 60 PALMERS HILL ROAD | ||||||||
Address2: |   | ||||||||
City: | STAMFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 06902 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033243167 | ||||||||
FaxNumber: | 2033582327 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
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 | 1041C0700X | 004084 | CT | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
ID | Type | State | Issuer | Description | 004172912 | 05 | CT |   | MEDICAID | 004172920 | 05 | CT |   | MEDICAID |