Provider Demographics
NPI:1518188432
Name:NICODEMUS, KATHRYN (LICSW)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:NICODEMUS
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 1:31 LOWDEN ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-6123
Mailing Address - Country:US
Mailing Address - Phone:401-723-6232
Mailing Address - Fax:
Practice Address - Street 1:19 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-6306
Practice Address - Country:US
Practice Address - Phone:401-845-2269
Practice Address - Fax:401-848-4192
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW006331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical