Provider Demographics
NPI:1194834838
Name:NICHOLSON, DORINDA M (LCSW)
Entity Type:Individual
Prefix:
First Name:DORINDA
Middle Name:M
Last Name:NICHOLSON
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 1:901 NE INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64086-5544
Mailing Address - Country:US
Mailing Address - Phone:816-347-3030
Mailing Address - Fax:
Practice Address - Street 1:6801 E 117TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64134-3701
Practice Address - Country:US
Practice Address - Phone:816-554-5517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0009951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO3071238CMedicare UPIN