Provider Demographics
NPI:1568511954
Name:MCCLUSKY, NICKI S (LPC, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:NICKI
Middle Name:S
Last Name:MCCLUSKY
Suffix:
Gender:F
Credentials:LPC, LCSW
Other - Prefix:MISS
Other - First Name:NICKI
Other - Middle Name:R
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC, LCSW
Mailing Address - Street 1:721 VILLA CAPRI CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-3604
Mailing Address - Country:US
Mailing Address - Phone:314-432-2549
Mailing Address - Fax:
Practice Address - Street 1:721 VILLA CAPRI CT
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3604
Practice Address - Country:US
Practice Address - Phone:314-432-2549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0025681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO45-0537507Medicare ID - Type UnspecifiedEI N NUMBER