Provider Demographics
NPI:1447704275
Name:PHELAN, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:PHELAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 MIECASKLY DR
Mailing Address - Street 2:
Mailing Address - City:NEW GLOUCESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04260-4670
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 MIECASKLY DR
Practice Address - Street 2:
Practice Address - City:NEW GLOUCESTER
Practice Address - State:ME
Practice Address - Zip Code:04260-4670
Practice Address - Country:US
Practice Address - Phone:207-774-3570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-10
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC173801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical