Basic Information
Provider Information | |||||||||
NPI: | 1740702547 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NIEVES | ||||||||
FirstName: | DOMINGO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | CLINICAL COORDINATOR | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NIEVES | ||||||||
OtherFirstName: | DOMINGO | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: | JR. | ||||||||
OtherCredential: | CLINICAL COORDINATOR | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 2257 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 011071905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137333488 | ||||||||
FaxNumber: | 4137317381 | ||||||||
Practice Location | |||||||||
Address1: | 2225 MAIN ST. | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 01107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4137333488 | ||||||||
FaxNumber: | 4137317381 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2017 | ||||||||
LastUpdateDate: | 07/13/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 3080010 | 05 | NH |   | MEDICAID | 1301829 | 05 | MA |   | MEDICAID |