Provider Demographics
NPI:1083705537
Name:NISSEN, RUTH (LCSW-C,CCDC)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:
Last Name:NISSEN
Suffix:
Gender:F
Credentials:LCSW-C,CCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 KNIGHTS ISLAND ROAD
Mailing Address - Street 2:
Mailing Address - City:EARLEVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21919
Mailing Address - Country:US
Mailing Address - Phone:410-275-1686
Mailing Address - Fax:
Practice Address - Street 1:VAMHCS
Practice Address - Street 2:SARRTP/22H
Practice Address - City:PERRY POINT
Practice Address - State:MD
Practice Address - Zip Code:21902
Practice Address - Country:US
Practice Address - Phone:410-642-2411
Practice Address - Fax:410-642-1108
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD052831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical