Healthcare Provider Details

I. General information

NPI: 1316144652
Provider Name (Legal Business Name): DONNA KAY NICHOLSON MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 MAPLE ST
FARMINGTON MO
63640-1955
US

IV. Provider business mailing address

1430 OLIVE ST STE 400
SAINT LOUIS MO
63103-2303
US

V. Phone/Fax

Practice location:
  • Phone: 314-315-7645
  • Fax:
Mailing address:
  • Phone: 314-206-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCS2309
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCS2309
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: