Provider Demographics
NPI:1184824492
Name:GAINES, NICOLE L (MSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:L
Last Name:GAINES
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17295 CHESTERFIELD AIRPORT RD STE 200
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1423
Mailing Address - Country:US
Mailing Address - Phone:314-921-1140
Mailing Address - Fax:
Practice Address - Street 1:17295 CHESTERFIELD AIRPORT RD STE 200
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1423
Practice Address - Country:US
Practice Address - Phone:314-921-1140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-24
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040045971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499425304Medicaid
MO499425304Medicaid