Provider Demographics
NPI:1134240864
Name:NICHOLSON, ANGELYN (MSSW, LCSW)
Entity type:Individual
Prefix:
First Name:ANGELYN
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MSSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E SPRINGDALE AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37917-5033
Mailing Address - Country:US
Mailing Address - Phone:865-309-5880
Mailing Address - Fax:
Practice Address - Street 1:400 E SPRINGDALE AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-5033
Practice Address - Country:US
Practice Address - Phone:865-309-5880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR104100000X
TN62741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000WCQLVMedicare ID - Type Unspecified
OR126370Medicaid