Provider Demographics
NPI:1548244254
Name:NICKERSON, CAROL J SUTHERLAND (LICSW BCD)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:J SUTHERLAND
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:LICSW BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 563
Mailing Address - Street 2:
Mailing Address - City:NORTH CHATHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02650-0563
Mailing Address - Country:US
Mailing Address - Phone:508-432-5640
Mailing Address - Fax:508-432-5659
Practice Address - Street 1:915 ROUTE 28
Practice Address - Street 2:
Practice Address - City:HARWICH
Practice Address - State:MA
Practice Address - Zip Code:02645-3448
Practice Address - Country:US
Practice Address - Phone:508-432-5640
Practice Address - Fax:508-432-5659
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1023047103T00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P06795OtherBCBS
1890743OtherMBHP
762332OtherTUFTS
184437000OtherMAGELLAN
762332OtherTUFTS