Provider Demographics
NPI:1508072562
Name:NICHOLS, BRENT (MA, LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MA, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 W 9TH ST
Mailing Address - Street 2:#1G
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8971
Mailing Address - Country:US
Mailing Address - Phone:212-254-5286
Mailing Address - Fax:
Practice Address - Street 1:26 W 9TH ST
Practice Address - Street 2:#1G
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8971
Practice Address - Country:US
Practice Address - Phone:212-254-5286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY074854-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical