MEDICARE: LYNDA KAYE NICKLE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	002832	MO

General Provider Information

NPI Number	:	1417178906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYNDA KAYE NICKLE LCSW

Provider Business Mailing Address
First Line	:	3322 S CAMPBELL AVE STE T-1
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65807-4980
Country	:	US
Telephone Number	:	417-220-4480
Fax Number	:	417-414-0017

Provider Business Practice Location Address
First Line	:	3322 S CAMPBELL AVE STE T-1
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65807-4980
Country	:	US
Telephone Number	:	417-220-4480
Fax Number	:	417-414-0017

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	07/02/2024

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