Provider Demographics
NPI:1629252739
Name:NICHOLS, SANDRA EILEEN (MSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:EILEEN
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 19TH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-3700
Mailing Address - Country:US
Mailing Address - Phone:309-779-7600
Mailing Address - Fax:309-779-7252
Practice Address - Street 1:106 19TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-3700
Practice Address - Country:US
Practice Address - Phone:309-779-7600
Practice Address - Fax:309-779-7252
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490048831041C0700X
IA052551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK49865Medicare PIN