Provider Demographics
NPI:1831619329
Name:NICKERSON, ELIZABETH (LCSW)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:ELLIS-CRUZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7401 PURPLE FRINGE RD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-6382
Mailing Address - Country:US
Mailing Address - Phone:219-308-8855
Mailing Address - Fax:
Practice Address - Street 1:2301 YALE BLVD SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4228
Practice Address - Country:US
Practice Address - Phone:505-272-1379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
IN34008210A1041C0700X
NMC-06307104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical