Provider Demographics
NPI:1013039635
Name:NICHOLS, PATRICIA DIANE (ACSW)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:DIANE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:NICHOLS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LICSW
Mailing Address - Street 1:PO BOX 2008
Mailing Address - Street 2:
Mailing Address - City:LENOX
Mailing Address - State:MA
Mailing Address - Zip Code:01240-5008
Mailing Address - Country:US
Mailing Address - Phone:413-770-1928
Mailing Address - Fax:650-763-4566
Practice Address - Street 1:45 WALKER ST STE 2
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LENOX
Practice Address - State:MA
Practice Address - Zip Code:01240-2765
Practice Address - Country:US
Practice Address - Phone:413-770-1928
Practice Address - Fax:650-763-4566
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY26806-091041C0700X
MA1164671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN47611Medicare ID - Type UnspecifiedPSYCHOTHERAPY 90806