Healthcare Provider Details

I. General information

NPI: 1457655185
Provider Name (Legal Business Name): LISA M NICHOLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5221 PARAMOUNT PKWY STE 220
MORRISVILLE NC
27560-5490
US

IV. Provider business mailing address

212 CARMEN LN SUITE 201
SANTA MARIA CA
93458-7769
US

V. Phone/Fax

Practice location:
  • Phone: 984-215-6641
  • Fax: 984-215-4053
Mailing address:
  • Phone: 805-739-8706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC011899
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: