Healthcare Provider Details

I. General information

NPI: 1003813957
Provider Name (Legal Business Name): TERESA J NICHOLS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 09/18/2025
Certification Date: 09/18/2025
Deactivation Date: 03/21/2006
Reactivation Date: 04/06/2006

III. Provider practice location address

500 HIGHWAY J
HAYTI MO
63851-1200
US

IV. Provider business mailing address

500 HIGHWAY J
HAYTI MO
63851-1200
US

V. Phone/Fax

Practice location:
  • Phone: 573-359-1200
  • Fax:
Mailing address:
  • Phone: 573-359-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2002007253
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: