Healthcare Provider Details

I. General information

NPI: 1518709559
Provider Name (Legal Business Name): STEFAN NICKUM LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3993 VT ROUTE 100
GRANVILLE VT
05747-9747
US

IV. Provider business mailing address

3993 VT ROUTE 100
GRANVILLE VT
05747-9747
US

V. Phone/Fax

Practice location:
  • Phone: 206-818-2439
  • Fax:
Mailing address:
  • Phone: 206-818-2439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number089.0134493
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: