Provider Demographics
NPI:1477684801
Name:NICHOLS, PATRICK FRANCIS (LCSW CSAC)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:FRANCIS
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:LCSW CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2241 RYAN DR
Mailing Address - Street 2:
Mailing Address - City:DODGEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53533-9274
Mailing Address - Country:US
Mailing Address - Phone:608-827-7220
Mailing Address - Fax:608-827-7223
Practice Address - Street 1:6502 GRAND TETON PLZ
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1047
Practice Address - Country:US
Practice Address - Phone:608-827-7220
Practice Address - Fax:608-827-7223
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4082-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI13683OtherADDICTION COUNSELOR
WI4082-123OtherLICENSED SW
WI39644000Medicaid