Healthcare Provider Details

I. General information

NPI: 1568425320
Provider Name (Legal Business Name): ANNE E. NICKERSON L.I.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23030 STATE ROUTE 73
WEST PORTSMOUTH OH
45663-8861
US

IV. Provider business mailing address

941 MARKET ST
PIKETON OH
45661-9757
US

V. Phone/Fax

Practice location:
  • Phone: 740-858-1063
  • Fax: 740-858-9140
Mailing address:
  • Phone: 740-289-2371
  • Fax: 740-289-4291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI0005226
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: