Provider Demographics
NPI:1568425320
Name:NICKERSON, ANNE E (LISW)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:E
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:941 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:PIKETON
Mailing Address - State:OH
Mailing Address - Zip Code:45661-9757
Mailing Address - Country:US
Mailing Address - Phone:740-289-2371
Mailing Address - Fax:740-289-4291
Practice Address - Street 1:23030 STATE ROUTE 73
Practice Address - Street 2:
Practice Address - City:WEST PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45663-8861
Practice Address - Country:US
Practice Address - Phone:740-858-1063
Practice Address - Fax:740-858-9140
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00052261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0188623Medicaid
NISW76981Medicare ID - Type Unspecified