=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740808344
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VIRGINIA NIX LICSW, PIP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2020
-----------------------------------------------------
Last Update Date | 04/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1117 22ND ST S UNIT 105
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35205-2813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-538-3504
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 SHARPSBURG CIR
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35213-1726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-218-6660
-----------------------------------------------------
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 | 4381C
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------