Provider Demographics
NPI:1942471917
Name:NICHOLS, LISA H (LCSW, RN, BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:H
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LCSW, RN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 SAILORS DR STE 131
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-3747
Mailing Address - Country:US
Mailing Address - Phone:706-636-1386
Mailing Address - Fax:706-636-1396
Practice Address - Street 1:216 SAILORS DR STE 131
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-3747
Practice Address - Country:US
Practice Address - Phone:706-636-1386
Practice Address - Fax:706-636-1396
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0006181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical