Provider Demographics
NPI:1922796705
Name:NICKERSON, SCOTT ARNOLD
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ARNOLD
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 FULTON AVE UNIT A
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-7229
Mailing Address - Country:US
Mailing Address - Phone:682-551-3633
Mailing Address - Fax:
Practice Address - Street 1:201 FULTON AVE UNIT A
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-7229
Practice Address - Country:US
Practice Address - Phone:682-551-3633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57457104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker