Provider Demographics
NPI:1336159615
Name:NICKERSON, MARK (LICSW)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:MA
Mailing Address - Zip Code:01002-3016
Mailing Address - Country:US
Mailing Address - Phone:413-256-0550
Mailing Address - Fax:413-256-0550
Practice Address - Street 1:441 WEST ST
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01002-2997
Practice Address - Country:US
Practice Address - Phone:413-256-0550
Practice Address - Fax:413-256-0550
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104628101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health