Provider Demographics
NPI:1558496919
Name:NICKLEN, GERALD DAVID (PHD, LICSW)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:DAVID
Last Name:NICKLEN
Suffix:
Gender:M
Credentials:PHD, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9950 US HIGHWAY 98 W LOT F6
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32550-4994
Mailing Address - Country:US
Mailing Address - Phone:850-543-7776
Mailing Address - Fax:
Practice Address - Street 1:9950 US HIGHWAY 98 W LOT F6
Practice Address - Street 2:
Practice Address - City:MIRAMAR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32550-4994
Practice Address - Country:US
Practice Address - Phone:850-543-7776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC3026341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical