Provider Demographics
NPI:1003813957
Name:NICHOLS, TERESA J (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:J
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:BLODGETT
Mailing Address - State:MO
Mailing Address - Zip Code:63824-0128
Mailing Address - Country:US
Mailing Address - Phone:573-703-6667
Mailing Address - Fax:573-748-2291
Practice Address - Street 1:421 LINE STREET
Practice Address - Street 2:
Practice Address - City:NEW MADRID
Practice Address - State:MO
Practice Address - Zip Code:63869-1733
Practice Address - Country:US
Practice Address - Phone:573-748-2592
Practice Address - Fax:573-748-2291
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2012-04-20
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
MO200020072531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO495072241Medicaid