=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043336324
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE M NICKERSON LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 05/30/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12 MARKET SQUARE SUITE 2
-----------------------------------------------------
City | AMESBURY
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-285-8265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 LOW ST
-----------------------------------------------------
City | NEWBURYPORT
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01950-3535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 857-285-8265
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1369
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 2096
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 121121
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------