Provider Demographics
NPI:1619142767
Name:NICKELSON, AUTUMN
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:NICKELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 10TH STREET, SUITE 211
Mailing Address - Street 2:NORTHWEST CENTER FOR BEHAVIORAL HEALTH
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801
Mailing Address - Country:US
Mailing Address - Phone:580-571-3231
Mailing Address - Fax:580-571-8609
Practice Address - Street 1:1222 10TH STREET, SUITE 211
Practice Address - Street 2:NORTHWEST CENTER FOR BEHAVIORAL HEALTH
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801
Practice Address - Country:US
Practice Address - Phone:580-571-3231
Practice Address - Fax:580-571-8609
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK38471041C0700X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200407870Medicaid