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General NPI Number Information
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NPI Number | 1891260782
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Entity Type | Individual
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Provider Name | BONNIE NICHOLLS LCSW
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Gender | Female
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Dates
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Enumeration Date | 10/08/2018
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Last Update Date | 10/08/2018
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Provider Practice Location Address
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Address Line | 860 S ASPEN AVE
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City | BROKEN ARROW
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State | OK
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Zip | 74012-4803
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Country | US
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Telephone | 918-258-6545
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Fax |
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Provider Business Mailing Address
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Address Line | 25547 MURPHY CT
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City | CLAREMORE
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State | OK
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Zip | 74019-4503
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Country | US
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Telephone | 918-706-1038
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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 | 6486
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License Number State | OK
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