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General NPI Number Information
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NPI Number | 1124452008
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Entity Type | Individual
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Provider Name | LACEY A NICHOLS LCSW
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Gender | Female
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Dates
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Enumeration Date | 08/27/2013
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Last Update Date | 11/02/2023
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Provider Practice Location Address
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Address Line | 1210 DRY HOLLOW RD STE 4 1/2
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City | THE DALLES
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State | OR
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Zip | 97058-3167
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Country | US
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Telephone | 541-240-8938
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Fax |
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Provider Business Mailing Address
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Address Line | 1210 DRY HOLLOW RD STE 4 1/2
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City | THE DALLES
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State | OR
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Zip | 97058-3167
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Country | US
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Telephone | 541-240-8938
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | L11457
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License Number State | OR
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