Healthcare Provider Details

I. General information

NPI: 1043143613
Provider Name (Legal Business Name): NICOLE THERESE BAUCUM LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 GEORGIA AVE
RICHMOND VA
23220-6805
US

IV. Provider business mailing address

1607 GEORGIA AVE
RICHMOND VA
23220-6805
US

V. Phone/Fax

Practice location:
  • Phone: 540-940-3203
  • Fax:
Mailing address:
  • Phone: 540-940-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904015541
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: