Provider Demographics
NPI:1235115353
Name:NICHOLAS, DONNA J (MSW, LCSW)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:J
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:J
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-339-1691
Mailing Address - Fax:812-337-2438
Practice Address - Street 1:272 N US HIGHWAY 231
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IN
Practice Address - Zip Code:47460-6635
Practice Address - Country:US
Practice Address - Phone:812-829-4871
Practice Address - Fax:812-829-0758
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34001239A1041C0700X, 101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN562970FMedicare ID - Type Unspecified
IN546470LMedicare ID - Type Unspecified
000000210889OtherANTHEM