Provider Demographics
NPI:1477869865
Name:NICKSON, LARISSA F (LCSW)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:F
Last Name:NICKSON
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 1:381 MCKINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19067-2359
Mailing Address - Country:US
Mailing Address - Phone:732-749-4267
Mailing Address - Fax:
Practice Address - Street 1:3 3RD ST STE 20
Practice Address - Street 2:
Practice Address - City:BORDENTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08505-1370
Practice Address - Country:US
Practice Address - Phone:732-749-4267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055370001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4144007Medicaid
NJ31-4011OtherMEDICARE