Healthcare Provider Details

I. General information

NPI: 1124758602
Provider Name (Legal Business Name): NICKOLAUS KING LCSW-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10715 CHARTER DR STE 130
COLUMBIA MD
21044-2892
US

IV. Provider business mailing address

4690 MILLENNIUM DR STE 300
BELCAMP MD
21017-1527
US

V. Phone/Fax

Practice location:
  • Phone: 410-656-9010
  • Fax:
Mailing address:
  • Phone: 410-656-9010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number28530
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW025578
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC06544300
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC200004715
License Number StateDC
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberQ1-0012675
License Number StateDE
# 6
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberQ1-0012675
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: