Healthcare Provider Details

I. General information

NPI: 1528752425
Provider Name (Legal Business Name): AMY C NICKUM MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 06/05/2023
Certification Date: 06/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 ELLIOTT AVE W STE 500
SEATTLE WA
98119-4292
US

IV. Provider business mailing address

8745 GREENWOOD AVE N APT 209
SEATTLE WA
98103-3650
US

V. Phone/Fax

Practice location:
  • Phone: 206-708-6432
  • Fax:
Mailing address:
  • Phone: 503-714-8064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSC61428109
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: