Provider Demographics
NPI:1114045671
Name:NICHOLSON, LISA L (LICSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:NICHOLSON
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 1:1 HOSPITAL CT
Mailing Address - Street 2:STE 410
Mailing Address - City:BELLOWS FALLS
Mailing Address - State:VT
Mailing Address - Zip Code:05101-1489
Mailing Address - Country:US
Mailing Address - Phone:802-463-3294
Mailing Address - Fax:802-463-1206
Practice Address - Street 1:29 ELM ST
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6511
Practice Address - Country:US
Practice Address - Phone:802-254-7511
Practice Address - Fax:802-254-7506
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-0000699103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN2757Medicaid
VT2158213OtherCIGNA
VT49345OtherBLUE CROSS
VTOVN2757Medicaid