Provider Demographics
NPI:1659365039
Name:NICKERSON, DARREN G (LCSW)
Entity Type:Individual
Prefix:
First Name:DARREN
Middle Name:G
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 SPUR RD
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-9403
Mailing Address - Country:US
Mailing Address - Phone:575-219-9293
Mailing Address - Fax:
Practice Address - Street 1:87 SPUR RD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-9403
Practice Address - Country:US
Practice Address - Phone:575-219-9293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040313371041C0700X
IDLCSW-256901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical