Provider Demographics
NPI:1649863754
Name:AMBERLY NICHOLS, LCSW, LLC
Entity type:Organization
Organization Name:AMBERLY NICHOLS, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-215-8313
Mailing Address - Street 1:3127 NORTHVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-6748
Mailing Address - Country:US
Mailing Address - Phone:574-215-8313
Mailing Address - Fax:
Practice Address - Street 1:3127 NORTHVIEW DR
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-6748
Practice Address - Country:US
Practice Address - Phone:574-215-8313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300030941Medicaid