Provider Demographics
NPI:1902157928
Name:WETHERELL, NICOLE (LCPC, LADC, CCS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WETHERELL
Suffix:
Gender:F
Credentials:LCPC, LADC, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5462
Mailing Address - Country:US
Mailing Address - Phone:207-767-0991
Mailing Address - Fax:207-767-0995
Practice Address - Street 1:57 EXCHANGE ST STE 402
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-5050
Practice Address - Country:US
Practice Address - Phone:207-200-7013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1164484093Medicaid