Healthcare Provider Details

I. General information

NPI: 1336184985
Provider Name (Legal Business Name): DEBORAH ANN NICHOLS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DEBORAH ANN SAPP LCSW

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 11/30/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 MDG 331 SIJAN AVENUE
WHITEMAN AFB MO
65305
US

IV. Provider business mailing address

509 MDG 331 SIJAN AVENUE
WHITEMAN AFB MO
65305
US

V. Phone/Fax

Practice location:
  • Phone: 660-687-4412
  • Fax:
Mailing address:
  • Phone: 660-687-4412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004672
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW004672
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier497884338
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer
# 2
Identifier23810
Identifier TypeOTHER
Identifier StateMO
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: