Provider Demographics
NPI:1891260782
Name:NICHOLLS, BONNIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:BONNIE
Middle Name:
Last Name:NICHOLLS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25547 MURPHY CT
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74019-4503
Mailing Address - Country:US
Mailing Address - Phone:918-706-1038
Mailing Address - Fax:
Practice Address - Street 1:860 S ASPEN AVE
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-4803
Practice Address - Country:US
Practice Address - Phone:918-258-6545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK64861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical