MEDICARE: DONNA J NICHOLAS MSW, LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	34001239A	IN

General Provider Information

NPI Number	:	1235115353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA J NICHOLAS MSW, LCSW

Provider Business Mailing Address
First Line	:	645 S ROGERS ST
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-2353
Country	:	US
Telephone Number	:	812-339-1691
Fax Number	:	812-337-2438

Provider Business Practice Location Address
First Line	:	272 N US HIGHWAY 231
Second Line	:
City	:	SPENCER
State	:	IN
Zip	:	47460-6635
Country	:	US
Telephone Number	:	812-829-4871
Fax Number	:	812-829-0758

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2005
Last Update Date	:	07/30/2014

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