Provider Demographics
NPI:1538445275
Name:SMITH, NICOLE (MA, BCBA)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:MR
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MONTIPAGNI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, BCBA
Mailing Address - Street 1:111 CHARTER OAK AVE
Mailing Address - Street 2:RIVER STREET AUTSIM PROGRAM AT COLTSVILLE
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1912
Mailing Address - Country:US
Mailing Address - Phone:860-298-9079
Mailing Address - Fax:860-722-9438
Practice Address - Street 1:111 CHARTER OAK AVE
Practice Address - Street 2:RIVER STREET AUTSIM PROGRAM AT COLTSVILLE
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1912
Practice Address - Country:US
Practice Address - Phone:860-298-9079
Practice Address - Fax:860-722-9438
Is Sole Proprietor?:No
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1-00-0342103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst