Provider Demographics
NPI:1558371856
Name:NICHOLS, GRETA AMARIS (LBASW)
Entity Type:Individual
Prefix:MRS
First Name:GRETA
Middle Name:AMARIS
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LBASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 WHITE ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5536
Mailing Address - Country:US
Mailing Address - Phone:810-966-3736
Mailing Address - Fax:
Practice Address - Street 1:3847 PINE GROVE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-4265
Practice Address - Country:US
Practice Address - Phone:810-966-3736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802084604104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker