Provider Demographics
NPI:1386007078
Name:NICKISON, RICHARD DENNIS (LSW)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DENNIS
Last Name:NICKISON
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10352 STATE ROUTE 139
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-9361
Mailing Address - Country:US
Mailing Address - Phone:740-577-5775
Mailing Address - Fax:740-286-0245
Practice Address - Street 1:418 CENTER ST
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1712
Practice Address - Country:US
Practice Address - Phone:740-776-2785
Practice Address - Fax:740-776-2793
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS00279061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical