Healthcare Provider Details

I. General information

NPI: 1811965270
Provider Name (Legal Business Name): CHERYL LYNN NICCUM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 ROGER BROOKE DRIVE BROOKE ARMY MEDICAL CENTER
FORT SAN HOUSTON TX
78234
US

IV. Provider business mailing address

2703 REDRIVER CREEK DR
SAN ANTONIO TX
78259-3541
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-5371
  • Fax: 210-916-1602
Mailing address:
  • Phone: 210-916-5371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR039435-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: