Healthcare Provider Details

I. General information

NPI: 1154990232
Provider Name (Legal Business Name): BRIANA RENEE NICHOLSON MS, RADC-P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 MAPLE ST
FARMINGTON MO
63640-1955
US

IV. Provider business mailing address

2034 JACOB LN
FARMINGTON MO
63640-7667
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-5353
  • Fax:
Mailing address:
  • Phone: 573-366-0512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17825
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: