Provider Demographics
NPI:1013588490
Name:NICHOLS, ELENA SERGEYEVNA (LICSW)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:SERGEYEVNA
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:486 MAIN ST APT A
Mailing Address - Street 2:
Mailing Address - City:WINOOSKI
Mailing Address - State:VT
Mailing Address - Zip Code:05404-1338
Mailing Address - Country:US
Mailing Address - Phone:802-865-3450
Mailing Address - Fax:
Practice Address - Street 1:486 MAIN ST APT A
Practice Address - Street 2:
Practice Address - City:WINOOSKI
Practice Address - State:VT
Practice Address - Zip Code:05404-1338
Practice Address - Country:US
Practice Address - Phone:802-865-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089.01195661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical