Provider Demographics
NPI:1013985597
Name:NICHOLS, REBECCA A (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:NICHOLS
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 1:210 SIMMONS ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4750
Mailing Address - Country:US
Mailing Address - Phone:865-970-9800
Mailing Address - Fax:865-983-4518
Practice Address - Street 1:210 SIMMONS ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801
Practice Address - Country:US
Practice Address - Phone:865-970-9800
Practice Address - Fax:865-983-4518
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3927817Medicaid