Provider Demographics
NPI:1235686353
Name:WILSON, NICOLE CHAGGARIS (LICSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:CHAGGARIS
Last Name:WILSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:CHAGGARIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:1470 BEACON ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-2628
Mailing Address - Country:US
Mailing Address - Phone:617-277-6140
Mailing Address - Fax:
Practice Address - Street 1:1470 BEACON ST
Practice Address - Street 2:SUITE B
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-2628
Practice Address - Country:US
Practice Address - Phone:617-277-6140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1183761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical