Basic Information
| Provider Information | |||||||||
| NPI: | 1043647373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BORUSIEWICZ | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LMSW,MSW,BSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 3RD FLOOR-HOME BASED SERVICES | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2013 | ||||||||
| LastUpdateDate: | 06/06/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 000826 | CT | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 060669107 | 01 | CT | AETNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | HEALTHYCT WELLMORE GRP/FACILITY | OTHER | NOT ELIGIBLE | 01 | CT | MHN MANAGED HEALTH NETWORK | OTHER | 008065074 | 05 | CT | MEDICAID | NOT ELIGIBLE | 01 | CT | MHN TRICARENORTH | OTHER | CAQH | 01 | CT | 13540261 | OTHER | 060669107 | 01 | CT | UBH/OXFORD FREEDOM/LIBERTY WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | UBH/UNITED HEALTHCARE WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | ANTHEM BCBS OF CT WELLMORE GRP/FACILITY | OTHER | 060669107 | 01 | CT | OPTUM BEHAVIORAL HEALTH WELLMORE GRP/FACILITY | OTHER | PENDING | 01 | CT | CIGNA BEHAVIORAL HEALTH | OTHER | 060669107 | 01 | CT | UBH-CONNECTICARE WELLMORE GRP/FACILITY | OTHER | D339123-141 E MAIN | 01 | CT | BEACON HEALTH STRATEGIES | OTHER |