Provider Demographics
NPI:1518029479
Name:NICKERSON, DEBRA H (LICSW)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:H
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 FLYNN AVE
Mailing Address - Street 2:3J
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-5429
Mailing Address - Country:US
Mailing Address - Phone:802-488-6900
Mailing Address - Fax:802-488-6919
Practice Address - Street 1:1138 PINE ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5353
Practice Address - Country:US
Practice Address - Phone:802-488-6600
Practice Address - Fax:802-488-6919
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT089-00009451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1014509Medicaid
VT1014509Medicaid