Provider Demographics
NPI:1447410071
Name:NICHOLSON, CAROLYN J (LMSW)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:J
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20955 VIRGINIA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2381
Mailing Address - Country:US
Mailing Address - Phone:248-219-5493
Mailing Address - Fax:248-354-3816
Practice Address - Street 1:20955 VIRGINIA ST
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2381
Practice Address - Country:US
Practice Address - Phone:248-219-5493
Practice Address - Fax:248-354-3816
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X, 1041C0700X, 106H00000X
MIN242108275628104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist