Healthcare Provider Details

I. General information

NPI: 1659365039
Provider Name (Legal Business Name): DARREN G NICKERSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 SPUR RD
CLOVIS NM
88101-9403
US

IV. Provider business mailing address

87 SPUR RD
CLOVIS NM
88101-9403
US

V. Phone/Fax

Practice location:
  • Phone: 575-219-9293
  • Fax:
Mailing address:
  • Phone: 575-219-9293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2004031337
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-25690
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: