Provider Demographics
NPI:1881220051
Name:NICHOLSON, TERESA L DOMINIQUE (LLMSW)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:L DOMINIQUE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:L DOMINIQUE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW
Mailing Address - Street 1:500 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4224
Mailing Address - Country:US
Mailing Address - Phone:989-797-3400
Mailing Address - Fax:989-799-0206
Practice Address - Street 1:500 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4224
Practice Address - Country:US
Practice Address - Phone:989-797-3400
Practice Address - Fax:989-799-0206
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-19
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801106528104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker