Provider Demographics
NPI:1659864890
Name:NICHOLS, KATRINA MARY (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:KATRINA
Middle Name:MARY
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:MARY
Other - Last Name:NICKERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:237 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:MARSTONS MILLS
Mailing Address - State:MA
Mailing Address - Zip Code:02648-1054
Mailing Address - Country:US
Mailing Address - Phone:603-801-2386
Mailing Address - Fax:
Practice Address - Street 1:456 FLAX POND RD
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:MA
Practice Address - Zip Code:02631-2133
Practice Address - Country:US
Practice Address - Phone:604-801-2386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW026391041C0700X
MA1217241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical