Healthcare Provider Details

I. General information

NPI: 1548244254
Provider Name (Legal Business Name): CAROL J SUTHERLAND NICKERSON LICSW BCD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 ROUTE 28
HARWICH MA
02645-3448
US

IV. Provider business mailing address

PO BOX 563
NORTH CHATHAM MA
02650-0563
US

V. Phone/Fax

Practice location:
  • Phone: 508-432-5640
  • Fax: 508-432-5659
Mailing address:
  • Phone: 508-432-5640
  • Fax: 508-432-5659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1023047
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1023047
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: